Cite this post as:
Scott Weingart, MD FCCM. ThinkingCC COVID Respiratory Management Webinar. EMCrit Blog. Published on April 12, 2020. Accessed on October 5th 2024. Available at [https://emcrit.org/emcrit/covid-respiratory-management/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: April 12, 2020
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Can you talk about heparin transition in these patients with coagulopathy. They get put on heparin gtt- but when do you transition them – Coumadin/lovenox etc. Any direction there would be helpful.
laura mentioned that Italian studies describe 6% of intubations resulting in arrest. That is very concerning. Can you link this study?
We are acknowledging that Covid causes profound and intractable hypoxia often in the absence of ARDS. Is anyone talking about why or how?
Don’t we know covid attacks the ACE2 protein & that ACE2 is a vasodilator? Wouldn’t it then make sense if this hypoxia without ARDS is caused by vasoconstrction? Shouldn’t we be looking into treating with pulmonary vasculature dialaters?
It looks like, at least at the beginning, there is a loss of hypoxic vasoconstriction, leading to marked V/Q abnormalities. This without stiff nor “baby lung”. In Europe in the 80s and 90s a drug called Almitrine was used for ARDS, as it restored HPV. It might be time for a comeback.
Thanks for the reply!
I know that Gattinoni postulates loss of vasoconstriction, but is there any evidence for that? Very well could be, but from what I’ve read about covid and ACE2, too much constriction seems more plausible.
? Like RSV does to the nose, COVID does to alveoli: copious secretions. Wants to aerosolize itself as much as possible. Causes complete shunt. The Hgb going through receive zero O2. Back in the heart, it this mixes w the Hgb from the uneffected portions.
any one done diffusion capacity or v/q testing on these patients
interesting 5 covid cases in china rxd with hyperbaric oxygen .
https://www.ihausa.org/Hyperbaric_oxygen_therapy_in_the_treatment_ofCOVID-19_Severe_Cases.pdf
large scale hyperbaric oxygen ” tank” proposal using airplanes as “tanks” as hospital units …https://mozg4d.com/
In our hospital, we use a large helium-filled clear garbage bag to extubate patients.
The effect a pressurized room has on the human body?
Hemodynamic Effects of Continuous Positive and Negative Pressure Breathing in Normal Man
I’m also picturing viral gaseous clouds in proximity to these facilities :/
any concern with y’all?
Scott – your undistressed patient with sats of 58% – was he clinically cyanosed??
Scott,
Taking COVID L vs H off the table, if a patient becomes profoundly hypoxic during intubation, what vent settings would you set for immediate post intubation? The question is based on a no bagging post intubation strategy.
Would like to have vent parameters discussed with RT prior to intubation and pre-set.
Thanks
Brendan C
To conserve PPE our EMS and some ER staff have been using rain suits. These are then cleaned with virex and reused.
Do y’all have data on extubation rates using low PEEP strategy at your ICUs? Many of our crit care guys here in New Orleans are using high PEEP ladders that ARDSnet produces and getting extubation rates of around 40% at our tertiary care center for all patients admitted to ICU (40% of intubated pts expire, 20% not needed to be intubated and stay on HFNC/BiPap. This data is from 3/10-4/1) (1). Would be interesting to see how they compare. Different patient populations and I’m sure many other management differences but this seems to be a major difference in management strategies… Read more »
You guys are awesome for putting the time into this video! Very helpful for those of us that are just starting to see our upswing! Please keep sharing your knowledge! We-and our patients-will benefit from all of your experience moving forward.
I think by now all of you know The problem is not with the lungs, but with the individual Red cell! I see it as an Anaerobic, Host Cell pathigan, if not please do some research on this type of pathogen. . I believe the virus is invading the red cell releasing the iron within the cell so the red will not pick up 02 from the lungs.which would be counterproductive for the virus. within the virus it will feed and multiply, in patience that have a poor immune system! With a good immune system the atrocities will envelope the… Read more »
Diamox-Acetazolamide for high altitude sickness. Covid-19 acts like this. All the same symptoms.
Ozone injection? Are you serious? It’s a poison to living tissue, so it’s like the comment of drinking bleach or something like that. Rather silly to disinfect the body and kill the patient with a treatment so don’t expect a serious answer from a doctor. It does oxidation like any poison, and the only other gas oxidation which will decay tissues that is well known is Mustard Gas. Of course OZONE and MUSTARD GAS will kill the virus AND the patient.
Pneumocystis jirovecii: I have way to much time on my hands! What if the Indian scientists were right and there is a HIV insertion in Covid-19. There is a substance in the lungs of Covid-19 patients. I have to assume it has been tested so as to discount this possibility. Pneumocystis jirovecii has a predilection to infect the lung in at-risk individuals. Microscopic examination reveals that Pneumocystis attaches to Type I alveolar epithelium, which allows the fungus to transition from its small trophic form to the larger cystic form. Adherence of Pneumocystis to alveoli is not the singular cause of… Read more »
You have a good idea…there is something more going on..if we work together we can fibd the answers
Pneumocystis jirovecii: I have way to much time on my hands! What if the Indian scientists were right and there is a HIV insertion in Covid-19. There is a substance in the lungs of Covid-19 patients. I have to assume it has been tested so as to discount this possibility. Pneumocystis jirovecii has a predilection to infect the lung in at-risk individuals. Microscopic examination reveals that Pneumocystis attaches to Type I alveolar epithelium, which allows the fungus to transition from its small trophic form to the larger cystic form. Adherence of Pneumocystis to alveoli is not the singular cause of… Read more »
I am not a doctor, so please bear with my lack of industry terminology. If a patient comes in as a happy with a sat of 70, breathing less than 20, has anyone tried super low peep/no peep APRV and highish fio2, and let them breath on their own? (isnt that the same as the helmet?) I do love the adult tummy time- but obviously that obesity is a problem. Applying the same baby theory, if the baby cant flip over themselves, don’t let them sleep on their belly. There is one thing that I don’t hear anything about- is… Read more »
I’m attempting to get information to Dr. Cameron Kyle-Slidell, I have been trying to have this checked by experts to no avail, please review in case!
http://web.archive.org/web/20200405061401/https://medium.com/@agaiziunas/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-91182386efcb
What if there is a HIV insertion and that is causing the weird clotting issues in Clovis-19 patients. the weiAbnormalities in the blood clotting process develop as HIV disease gets worse say US doctors, putting patients at increased risk of potentially fatal clots. Researchers first noted eight years ago that HIV-infected people appear to be at increased risk of a blood clot in the veins, or venous thromboembolism (VTE). The blood clots cause most problems when they develop in a vein far below the surface of the skin, forming a deep vein thrombosis (DVT). Glossary protein acute infection pulmonary exclusion… Read more »
a side note here….but it was brought up.
though there seems to be some similarity with HAPE i’m not seeing a cogent thread of explanation linking them.
HAPE is characterised by patchy oedema caused by ‘uneven’ pulmonary vasoconstriction, very much related to low partial pressure 02 and associated with pulmonary hypertension. IMHO there is no thorough mechanistic explanation for HAPE, and this extrapolation to COVID 19 pathophys seems premature.
it is exquisitely sensitive to increasing the pp02 via descent or hyoerbaric pressure (in godforesaken looking sealed O2 capsules/ coffins).
May the force be with you.
from remarkably covid low Australia.
Please contact Dr. Boros from UCLA He’s a research biochemist prof. He wants to share O exchange & delivery info to tissues based on Deutenomics principles. I’m sure you can get to the bottom of this covid tissue oxygenation problem. https://www.laszlogboros.com/
I think it has something to do with muscle….the virus is attacking at the muscular level. There is one factor we don’t usually include in our pulmonary health formula that we need to add in for the effects from this virus.
Its about movement, the last thing they want to do…..make them use their muscles. Make them as mobile as possible. You need to think about blood and oxygen flow through entire body. Not just on horizontal plane, vertically also. Sedation might be just the opposite of what they need. Pay attention to how swimmers do, that will help u find the missing link in your usual lung health formula.
The more I read about and watch your panel discussions, the more it sounds familiar to our babies with persistent pulmonary hypertension (PPHN). In your “Happy Hypoxemic” patients, are you seeing early echo signs of increased pulmonary pressures? When we suspect PPHN based on clinical and blood gas parameters, we immediately adjust our treatment plan to the following: 1. Maintain PaO2 80-100 mmHg and pCO2 in normal range, avoid acidosis 2. Maintain SpO2 >95% 3. Morphine preferable to fentanyl for sedation as morphine has pulmonary vasodilatory effects 4. Inhaled nitric oxide (iNO) at 20 ppm, if FiO2 need exceeds 50%… Read more »
This is an interesting webinar from Dr. Andrew Kaufman reviewing papers that have claimed to have fulfilled Koch’s postulates and leaves the viewer to beg the question of whether this is a viral disease at all . 1. We have never been able to isolate the virus but rather only obtain genetic material 2. We have not cultivated material in host cells and 3. We have not proved filter-ability. Many of the papers have been unable to meet ANY of the criteria of either Koch’s postulates or River criteria in the case of Covid19. Conclusion: coronavirus has never been proven… Read more »
Just stumbled across this interesting paper in re CF patients after watching the recent Kyle-Sidell video. It concerns P aeruginosa but concerns the general physiology of infection in CF patient lung physiology, membrane chemistry and related biofilm behavior. I link this in the hope it might illuminate or lead to new insights regarding some of the atypicality and paradox observed in the disease process phenomena described by Kyle-Sidell, which seems to play out in the microbiome and biofilm of the alveoli. What happens in the atypicality of the CF lung may help explain the unprecedented observations being described by Kyle-Sidell… Read more »
Not a doctor. No claim is made about medical knowledge. It would be nice to hear what therapeutics had been used, and anecdotal success (or lack thereof). Hydroxychloroquine has been used in Italy and NYC, and it would be nice to hear the results. There are also other potential therapeutics that have been discussed, e.g., Ivermectin, but I’m sure not clinically used (still interesting).
I have been trying to get some info to Sydell or really any of the panelist above some info on happy hypoxic / high altitude sickness/ HAPE model. How do I go about this, I don’t want to post publicly. Thanks
https://youtu.be/Rzu1AJRZJEI
I had this last year and my daughter showed signs of pulmarary htn with right sided heart failure as I noticed her jugular was distended intermittently. I think by putting these patients on any type of humidifed vent or other device you are making it worse and attracting more of this vector to the patient. I have been through all of this and now have right sided heart failure as a result of cavitary pne with covid. Think deeper about the cause, think outside the box…do you see it closer to water??? Is is possble that sea lice are the… Read more »
@cameronks
A group of scientists is discussing about pulmonary surfactant defficiency in COVID-19.
Is exogenous surfactant therapy for consideration?
Maybe change in surfactant composition after viral infection can also affect diffusion in the alveolar interface. There are also some post mortem studies of COVID lungs showing clear liquid jelly accumulation in the lungs, similar to wet drowning, perhaps hyaluronan and seems to be similar to preterm babies hyaline mambranes formation due to lack of surfactant. There are many other antiviral effects of surfactant.
https://www.researchgate.net/post/COVID-19_and_respiratory_distress-could_it_be_surfactant_deficiency_May_exogenous_surfactant_help
Covid-19 patients present with symptoms very similar to high altitude sickness. Diamox (Acetazolamide) has been used successfully to treat HAPE. Why isn’t this drug being looked into for possible covid-19 treatment?
I am not a medical professional but have been following Dr. Sidell’s observation that the symptoms of Covid patients are similar to High Altitude sickness. I ran across this video by this woman quoting Dr. Sidell who was treated for a brain CSF fluid buildup with Diamox. She researched it and found that the drug is also used to decrease fluid buildup in other organs like the lungs. and is a treatment for High Altitude sickness. Is it possible that this could be a line of research for a possible treatment using this type of drug? Here is a link… Read more »
I am a lay person but I’m also one of those people that has weirdly backwards reactions or over reactions to medications and medical procedures. One of those reactions is to a class of HBP medications known as ACE 2 inhibitors. It causes out of control BP (220/200 out of control – non medicated my BP is in the 140/85 range). I also get ALL the side effects of ACE2 inhibitors: Dry cough Increased potassium levels in the blood (hyperkalemia) Fatigue Dizziness Headaches Loss of taste All of these “side effects” of ACE2 inhibitors are also noted symptoms of covid… Read more »
I want to thank you all for this public conversation, for giving enough detail to inform a layperson/observer, and wish to laud you all on your mental acrobatics in outsmarting this trickster virus, or at least something so new it’s requiring much thinking out of the box. I’m in awe of nature, the natural world, and the rigorous, unending attempts to understand and, in the process, corral the beast. Thank you, thank you for sharing. Thank you for your hard work and efforts. (Without seeming too dramatic) You are my heroes!
Could covid19 be a blood disease?
I have a new treatment suggestion, which could be applied in addition to my earlier suggestion. The new suggestion relates to mucous membranes and the effect of attacks upon them by the coronavirus. The lungs and guts can both be attacked by the coronavirus, as they both have mucous membranes. However there is a significant difference: If the lungs are primarily attacked, then these can become blocked. The patient appears to suffer from altitude sickness, with insufficient oxygen. Proving fatal. The gut mucous membrane being attacked results in unpleasant diarrhoea, however if blood fluids are replenished via a drip, this… Read more »
Hi. Everyone is forgetting this is a Hepatic infectious disease. By sample, this COVID is found in fecal material as well as respiratory secretions.(blood also of course) The respiratory issue is secondary to the disease and although dramatic there are other things happening in the body. The liver has been essentially Hijacked. Remember, the liver not only deals with Glucogon/Glucose cycles, citric cycle, it works with the important fat and aminos required.(It’s an RNA virus, it interacts with phosphorus as part of its driving cycle) I have asked a few other researchers about securing biopsy samples of Adipose. Consider this:… Read more »
I am not an academic but my think tank has been focused on histamine. I am a presumptive patient of C19. This virus needs an all-in assault between researchers, doctors, and patients. I will get to the science piece of my independent research and reason for writing; but understand there are events that led to my connection between histamine and blood clotting factors; and that I’ve had a myriad of prescribed and OTC treatments to overcome many separate and ever-changing symptoms. It seems this virus wants to get to know ALL of you and likes to move around–like ah ha… Read more »
https://rodgerdp65.blogspot.com/2020/04/pneumonia.html
Are the blood saturation levels being measured by a pulse oximeter or blood gas analysis? How do you know that the pulse oximeter is accurate and the red vs IR wavelength ratio of light absorption isn’t being impacted by some odd feature of the disease or patient status?
Updated family ccp virus report Do you really think this is about the covid19 virus? Have we gotten rid of any flu virus in the past. We in fact learned to live with the many strands of virual infections. What makes anyone think this is going to be a short confinement to home quarters. COVID19 life saving treatment https://youtu.be/Rzu1AJRZJEI Staying at home does not cure or inoculate anyone from this virus. The covid19 lives on. It started with bat shit, then went to humans and will return to all mamals. That means the dogs and cats in the field, birds,… Read more »
I am posting a link to an article that appeared today in a newspaper in India referencing the findings of Italian autopsies. I’m not a medical doctor, and your group may already be aware of what Italy discovered, but in case you aren’t, here’s the link to the article connecting chlymidia pneumonia with the CoV19 in patients who experienced severe respiratory distress prior to death. https://www.google.com/amp/s/www.tribuneindia.com/news/nation/co-existence-of-coronavirus-with-bacterial-pathogen-a-major-cause-of-fatalities-88867