Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – COVID Ventilation Round Table Discussion. EMCrit Blog. Published on April 24, 2020. Accessed on April 24th 2024. Available at [https://emcrit.org/emcrit/emcrit-wee-covid-ventilation-round-table-discussion/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: April 24, 2020
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Great stuff as always. Re: Dr. Kyle-Sidell’s assertion that this represents a oxygen diffusion issue. There is evidence that pulmonary surfactant, in addition to preventing atelectasis, plays a significant role in oxygen diffusion. https://www.sciencedirect.com/science/article/pii/S0005273610001057 It seems that the major pulmonary findings of this disease (malignant atelectasis and hypoxemic respiratory failure) can be attributed, at least in part, to a lack of surfactant (which would make sense, given that the virus infects the cells responsible for producing surfactant in the lung). Exploring therapeutic surfactant may be more beneficial than considering carbonic anhydrase inhibitors (only 1 trial on clinicaltrials.gov currently listed in… Read more »
https://clinicaltrials.gov/ct2/show/NCT04362059 trial referenced by above post
bioinformatics projection of …
https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173
In paper cited above posting by .Paul Hansen “It has been recently reported that alveolar type II pneumocytes, the cells in charge of synthesizing and secreting pulmonary surfactant, express both chains of hemoglobin, being one the first non-hematopoyetic cell lines known to have this potential [23], [24]. ”
references 23, 24 are
https://www.ncbi.nlm.nih.gov/pubmed/15979582
https://www.ncbi.nlm.nih.gov/pubmed/16407281
Really enjoy listening to these round tables. I commend all of you for working so diligently to figure this out. I don’t trust our politicians but do have trust & faith in all of you! Keep up the great work and Thank You for doing what you do!! GodSpeed!
PS I am so excited whenever I see a new video pop up. Keep them coming. There’s a lot of idiots out here making negative comments. Please ignore!
Hi, I appreciate your quality stuff, we look forward to some interesting posts like this!
Hello, my name is Lorenzo Lopez. I am a paramedic in NM. Unfortunately I have had a recent outbreak in my wife’s family. 2 of 4 recovered 1 death and one still vented in hospital. Just an observation it was mentioned in one of your videos that Covid-19 patients seem like they have a form of altitude sickness. The family member I still hard in the hospital was flown from one of our smaller hospitals to our level 1 trauma faculty for possible ECMO treatment. They did not have to place him on ECMO as it seems that he responded… Read more »
If your question is: “has anyone seen significant improvement in patients after proning?”, then the answer is yes. A significant portion of these patients have marked improvement in hypoxemia with proning, sometimes for longer than in the PROSEVA trial. I’m confident we have avoided ECMO in patients due to aggressive proning.
Has anyone ever thought to use surfactant?
Great discussion as usual gentlemen. Though in NM we don’t have nearly as much volume as in NYC or elsewhere, my experience basically 100% matches what Rory was describing. If you define PEEP response by FiO2 requirement, I think you may be misled (in addition to Rory’s important reminder about how early on in ARMA high Vt group had better PaO2, several other ARDS therapies that improve PaO2 fail to improve outcome, including inhaled pulm vasodilators and paralytics). If you define optimal PEEP by compliance, these COVID patients aren’t responding to high PEEP, at least early in disease course. Early… Read more »
thanks for writing Pedro!! A lot to go through in there. In the ARMA trial, the reason sats were higher in the high Vt group is that super-high Vt is excellent at recruiting alveoli–you just hose the alveoli while you are doing it. Not really comparable to the situation we are discussing. Once you are at high fiO2, you will eventually get to the optimal PEEP or perhaps slightly higher with the table, it may just take a bit of time to get there compared to delta p. It does take a 2-variable problem and change it to 1. The… Read more »
Increasing the peep is not the answer. APRV is not the answer (maybe as the last resort). The answer is how to achieve a good amount of tidal volume with the lowest possible pressure being delivered. You can achieve this by using “Pressure Control mode” of ventilation and less sedation will be needed. Increasing the intra-thoracic pressure (high peep and APRV) puts more pressure to the heart and decreases the venous return.
Jeff,
Thanks for commenting. By definition, the lowest possible pressure for a desired Vt will be achieved by VC, not PC. Your comments re: APRV and PEEP are unfortunately overly simplistic–not quite how it works. Over-peeping (or Phigh) will do that. A recruiting level of those pressures offloads the right heart.
Great content as usual. A couple of points through my experience in the ICU with a couple dozen of these patients or so. 1) Many of these patients are VERY obese (BMI in the 40s plus). These patients have had significant recruitable consolidations especially after paralytics/intubation/sedation. APRV, prone ventilation and use of higher PEEP has been successful at improving shunt fraction and compliance/driving pressure. 2) Many of our patients were heavily sedated and prolonged hypoactive delirium and critical care acquired weakness has been a huge issue after lung mechanics have recovered. Less intense sédation regimes and upfront physio/mobilization as we… Read more »
I am so interested in everything your saying after watching most of my patients age 40-59 die a couple hours on the vent I wish I was working with such innovative doctors as yourself thank you for sharing your knowledge and experience I try to bring it in to work as suggestions to just please do something god damn different then what isn’t working!
Reposting my comment from 4/16 podcast. It looks like after a few days the conversation moves on? 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… Read more »
See Chemical Abstracts, v. 52, 22272 (1958) Supniewski J, Chrusciel T (1954). “[N-dimethyl-di-guanide and its biological properties]”. Archivum Immunologiae et Therapiae Experimentalis (in Polish). 2: 1–15. PMID 13269290.
Quoted from Chemical Abstracts, v.49, 74699 (1955) Supniewski J, Krupinska J (1954). “[Effect of biguanide derivatives on experimental cowpox in rabbits]”. Bulletin de l’Academie Polonaise des Sciences, Classe 3: Mathematique, Astronomie, Physique, Chimie, Geologie et Geographie (in French). 2(Classe II): 161–65.
Elsewhere, I have heard Physician’s venting low and fast in prone. Is this a strategy you have considered or tried? Theory being to reduce barotrauma. It might look weird on a Patient and to Nursing staff but Patients driving the PEEP and lighter sedation. (this might help with the confusing PEEP you’re observing? The curve?) Reducing inflammation has been the direction pharmacists have also appear to be looking at and discussing as well as the thrombotic issue. Novel K Hepatics, I’m not making any recommendations. I have heard of some DVT-ish sounding symptomatology occurring. We have 8 shifts in this… Read more »
More and more I think this topic is recapitulating the importance of the basic tenets of EBM. That’s fine until we start to believe that those personal experience reflect anything more than a thin flash of reality. So many discussions based around anecdotal experience with COVID (which is still the bulk of what we have) end up sounding like “This is what I’m seeing happen…” “Oh, we haven’t seen that.” We all know this to be true after repeated, endless, ad nauseam harsh lessons in the past — how many clever physiological ideas and early clinical “experiences” were later disproven… Read more »
I fear I may show some ignorance here, put an idea just occurred to me while listening to the Round table. It seems listening to this discussion that the main issue occurs either when someone requires intubation, or when the decision is made to intubate them and they were then placed on positive pressure ventilation. The decision for intubation it’s mainly based on their ability to maintain and oxygenation with spontaneous respiration. (this is where my ignorance is going to shine) Is it possible or even ethical/reasonable to consider ECMO while the patient is awake and spontaneously breathing using CPAP/BiPAP?… Read more »
Very useful and knowledgeable blog. I learn so many things from here. Thanks for sharing this blog with us.
Hi guys, very good conversation. My name is Jeff, respiratory therapist in VA for over 20 yrs. We are having success using PC-mode of ventilation during the early days of intubation. Why? Because you don’t need to heavily sedate them. In PC mode (15-20cmh20), the pt is able to breathe about 8cc/kg spontanous Vt with a capped pressure (thus protecting the lungs from barotrauma). These covid pts are air hungry to begin with. Initially, we use PRVC mode with low vt, pts become asynchronous with the vent and the pts will need to be sedated. Covid is a vasculitis problem… Read more »
Jeff, most of these comments are unfortunately slightly askew. 1. Given your comments re: PC, why don’t you try CPAP and let the pts breathe entirely on their own. 2. Given your experience with APRV, 1 of 2 things must be going on–1. You are doing it on a machine without true APRV or trying to jury-rig it on a machine that doesn’t offer it as a mode 2. you are setting it in a way incompatible with TCAV (see podcasts earlier this month). Many things can be said about APRV, but lack of pt comfort is not one of… Read more »
Hello Sir, 1. Why do you want CPAP in the very sickest COVIID patients to begin with? CPAP with or without PS is a weaning mode. You want to control and support their breathing. I haven’t seen in my over 20 yrs of practice start the sickest patients on CPAP mode of ventilation. 2. We use Servo-i ventilators. Specifically, we use BIVENT mode. Which is APRV for drager ventilators. Yes, you can have the pt spontaneously breathe on top of the P-high and P-low but we, as normal people do not normally breathe on top of P-high pressures of 20-30cnh20… Read more »
I am not a medical professional, but I have been following your conversation a bit, and I was wondering if the unusual Silent Hypoxemia you are seeing in your ERs and ICUs could have anything in common with Histotoxic hypoxia? It is my understanding ventilators would not be useful that circumstance either.
… perhaps because of an accumulation of reactive oxygen species due to some kind of damage?