Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew. EMCrit Blog. Published on March 30, 2020. Accessed on April 23rd 2024. Available at [https://emcrit.org/emcrit/stop-kneejerk-intubation/ ].
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.
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Original Release: March 30, 2020
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Ok, I realize that we are in a Pandemic, but I hear lots of “I thinks” and “my experience has been”. I get it, we have no good data. But that’s just it, we have no good data, The level of data here is about the same that supports hydroxychloroquine. The statement “within hours of intubation they need much higher peep than they would otherwise” is fallacious on its face. I think, I agree that CPAP might be where we end up, and I hope this is true. Just concerned that this is potentially an issue of selection bias. Are… Read more »
mentioned that it could be selection bias right up front. Not sure who said, “than they would otherwise,” but I believe the intent of the statement was “then I would have projected based on their preintubation course.” The statement I believe I made was that immediately after intubation, these pts require dramatically more PEEP than they did just before intubation. Many have noticed this phenomenon amongst the resus doctors who have been able to witness a large amount of COVID pts. I don’t think it is some subtle spidey sense that is leading many of these pts to be intubated–it… Read more »
As was discussed on the Wee, concern for aerosolization is what is stopping the use of non-invasive, You also have to make sure that there is a dual limb circuit with a HEPA filtered expiratory limb. We perhaps should have multiple patients in negative pressure rooms on non-invasive and providers wearing N95 and other proper PPE. BiPAP could also prevent a lot of intubations, though concern for higher risk of aerosolization.
Also, many we have seen do fit the definition of ARDS, and compliance is not uniformly fine.
Also, some autopsy results have shown lung changes consistent with ARDS.
Hi , I think this is what we are witnessing also by default , what you discussed in this Wee .We had to start putting patient ‘s on BIPAP /CPAP ,HFNC with face mask on the patient’s face ( ti limit aerolisation) and 15 litres NC with 100% mask , rather than letting them die ,as we are running out of vents . We even put 1 patient on BIPAP after intubation . We are tolerating and watching patient’s with O2 saturations up to 84-85% and the patient’s when patients are talking on their phones , while we stand outside… Read more »
What’s your recommendation if you don’t have enough negative pressure rooms to do HFNC/CPAP throughout your hospital? Having following this COVID oxygenation discussion since the beginning, it seems we’ve been recommending strongly against NIPPV given concern for aerosol production which led to the: titrate NC O2 to 6L and then intubate idea; as all these intermediate options were thought to be dangerous to healthcare workers? It does seem logical that some of these patients will probably improve during their hospitalization with NIPPV alone and not need intubation thus if we can avoid it, that would be ideal for many reasons,… Read more »
My preference would be Helmet based CPAP as an intermediate step with a good IP+C profile. No chance of mask leak to aerosolize. Outflow behind a viral filter and a PEEP valve (or even 25cm down in a column of water).
They are in short supply, but manufacturers are doing their best.
See http://www.helmetbasedventilation.com for info.
I am working on a locally produced design with a plastics shop, as the manufacturers are likely to be tapped out completely. Version 0.95 design drawings posted on my Facebook page, for lack of a better platform to communicate at the moment.
http://www.facebook.com/scott.loree.1
Thank you ! valuable links. I am having hard time convincing physicians and even pulmonologist and intensivist to do this .
I was glad to be directed on twitter back to this blog. I just put up a post discussing this issue on my error statistics philosophy blog. https://errorstatistics.com/2020/04/12/paradigm-shift-in-pandemic-vent-protocols/
I’m keen to look up the helmets, and learn more about this.
Regarding pts desatting early without obvious shunting –
Based on the paper below – what’s happening is the virus destroys much of the body’s Hgb, irreversibly deoxygenating it resulting in low SpO2 readings, which can be tolerated if the pt is not anemic. This is why it is drawing comparisons to HAPE – which starts out as purely low Hgb O2 saturation AND THEN pulmonary edema develops.
Could a PRBC transfusion provide new Hgb? Assuming the viral load is low enough to prevent this from recurring
https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173
I just read the same article posted on this guy’s tweet. Totally makes sense why people have such low sats but are fairly comfortable appearing for the given sat. Its not a lung issue its an oxygen carrying issue in the blood. Would starting meds stopping the protein in the virus that kicks the iron off the heme and then giving a transfusion work.? Sounds like a study waiting to happen.
https://twitter.com/yishan/status/1244717172871409666?s=20
Interesting idea, but you would expect to see paO2 and O2 sat dissociation early on, like in methemoglobinemia… In HAPE the sequence is low FiO2 – low pAO2 – low paO2 with low O2 sat.
I was thinking about PRBC transfusion as well, but thought about possibility of adding fuel to the fire similarly to knee jerk platelet transfusion in TTP/DIC. This article seems to indicate that free Hb allows virus to invade cells.
evolutamente.it/covid-19-pneumonia-inflammasomes-the-melatonin-connection/
Interesting to use Vitamin C to oxidize iron in Heme to possibly prevent this. Maybe combination of Vitamin C and transfusion?
The HEME redox dysfunction cited in the paper, when viewed through a biophysics lens, can be treated by grounding the patient to a negative field. It should supply electrons where the biochemistry is blocked. Just like jump starting a car. Similar to negative grounding to reduce chronic inflammation in. Rouleaux. Two biophysicists I Know did original research. Could be helpful.
Interesting podcast and I also began wondering about the possible template of a HAPE-like syndrome on top of the viral pneumonia (e.g. viral pneumonia slowly leads to hypoxia beyond which a HAPE-like presentation dominates) . I have always been amazed at how well some HAPE patients appear with horrible sats and HAPE does have some similar ground glass findings on CT. Has there been any data on pulmonary artery pressures in the sickest folks? Maybe there is a subset of patients with an exaggerated hypoxic vasoconstrictive response (these patients are prone to HAPE) that are worse off. If so, this… Read more »
That podcast was exactly what I needed to hear before my shift in two hours! The tachypnea is the crazy thing for me – pts w breathe over 50 for a while & seem to be pretty ok w it. Makes me feel better about staying the course. Do you find any meds help them settle down w the resp rate more comfortably? I have been using 20 ketamine hoping it might positively affect their respiration and facilitate sort of a trial of of they are going to be able to go w CPAP plan or will require intubation (conveniently… Read more »
Thanks for getting the word out regarding CPAP/NIPPV as an alternative to intubation. As you guys mention in the podcast and as other commenters have stated, we have to stay flexible and approach this with a open mind and solution-oriented mindset. I think the enthusiasm for early intubation comes from two places: 1) Traditional thinking about sat levels, P/F ratios, etc., as you guys discussed (i.e., cases where, based purely on numbers, most non-covid patients would be circling the drain without aggressive resp support). 2) Early anticipation of the need for invasive resp support to avoid having to do crash… Read more »
What do you think about microtheombolic dz? Increased pulmonary vascular resistance ?
Thank you for bringing this information into the open. At a time when rigorous randomized control trials will not express information in a timely, effective or articulate manner, in the interests of providing the best and most up to date care for our patients, “letters” and experience reports from those that have been on the front-line must be seen for their true value. I concur that “early intubation” may not benefit the individual patient, all the time, every time, COVID or otherwise. Intubation, like ECMO, can nearly always be pulled out when other modalities fail. Using it upfront to treat… Read more »
relatively good compliance with disproportionate hypoxia … sounds like possible major component of vasoplegia of the pulmonary vasculature. i note reported histology of an adenoca removed -coincidentally from covid patient – articulates prominent vascular engorgement !! maybe something about this virus induces pulmonary vasodilatation, out of proportion to what we usually see in respiratory failure due to other pathologies/pathogens. we are more often looking for drugs that lower pulmonary vasc resistance. a brief look for agents that might be used to counter this reveals quite a list of potential agents, some of which have quite favourable risk:benefit profiles [eg tramadol]… Read more »
I would think the opposite. It sounds like if anything, it would be pulmonary vasoconstriction and subsequent pulmonary hypertension that is the problem.
https://www.ncbi.nlm.nih.gov/pubmed/16484897/
“These findings suggest that high pulmonary vascular flows might exacerbate ventilator-induced lung injury independent of their effects on pulmonary vascular pressures.”
How do you weigh the risk to the medical staff of aerosolization with CPAP vs trying to keep the patient off of invasive ventilation?
Thank you Emcrit.. It is disturbing that there are such strong statements that have emerged regarding NIV in COVID 19. ANZICs and ACEM, our Australian intensive care and emergency colleges have both discouraged the use of NIV and recommend early intubation. Glad to see the UK intensive care society has suggested early CPAP.. The WHO and China National Health Commission suggest considering NIV or high flow. The reasons for discouraging NIV seem to based on two premises. 1 that NIV doesn’t work and 2. It is too high risk as an AGP. 1. In this paper published in JAMA Risk… Read more »
thank you Andre. since i posted the idea of pulmonary vasodilatation in this public forum, Luigi Gattinoni has put up a letter to the editor of the blue jnl, postulating the same hypothesis ! understandably his letter has generated more attention but it does not make my suggestion of a potential therapeutic strategy (ie using a pulm vasoconstrictor). i am more interested in the pathogenesis and potential treatment EARLY in the course of this disease – once the lung injury is established we are in the wretched ARDS boat. i suspect the reason we have made little real progress [incremental… Read more »
Any thoughts on wearing a cpap mask with PEEP valve attached over a HFNC (not hooked up to cpap machine). This should provide enough CO2 washout from the high flow. Patient could be taught to self titrate the PEEP valve to comfort and could take the mask on and off by themselves (in most cases).
Also, I’ve seen the set-up with the BVM on this website. I don’t think you need the BVM attached outside a pre-oxygenation scenario. This would be used as intermittent recruitment maneuver.
Hi Scott, I just listened to this Wee. I work part of the year in Breckenridge, Colorado. We are a high altitude pulmonary edema center of excellence. Many of the patients who present have an extremely low oxygen saturation, but look clinically well despite having type one respiratory failure. In 15 years I have never had to intubate a single patient with high altitude pulmonary edema. I have seen patients present with an oxygen saturation of 32% who are able to go home after a couple of hours of either CPAP or high flow oxygen. In many ways their mental… Read more »
Any thoughts of hyperbarics as a means to mitigate the risks of aerosolization. Or is this too cumbersome?
Hyperbarics out in the parking lot. 1918 going outside was the negative pressure room. Got a photo of using window screen to restrain uline bag tube to make disposable hyperbaric with home depot plumbing. Scroon down a few https://m.facebook.com/phrahnsis.musecal?ref=bookmarks
I don’t think there is any role for hyperbaric oxygen in COVID-19 patients. They have enough risk of pulmonary oxygen toxicity with standard therapy and would receive no benefit from excess dissolved plasma oxygen. I admit to a negative bias with regards to hyperbarics, but truly think anyone with that kind of an oxygen requirement would be better off with VVECMO.
if it was more plain air pressure, allowing less or no percentage of additional oxygen, would that be a beneficial trade off to avoid high oxygen levels arriving to the permanant lung tissues, differently from the oxegenation of blood system?
http://www.bioscience.org/2017/v9s/af/484/2.htm “Thus, the level of PaO2/FiO2 in the most severe patients was below 200-250, which is an accepted criterion for ARDS, regardless of its initial causes (97,98). The lethality level in the group of patients with severe blunt chest trauma accompanied by ARDS, who had received conventional therapy, was 77%. This high lethality corresponded to the lethality levels common for the most severe forms of ARDS, according to the literature of the 1980s-1990s, and even up to date (99,100). In contrast, in the group of patients with the same severe form of chest trauma who, in addition to the conventional… Read more »
Are any autopsies being done or is this wishful thinking considering drs, staff overwhemed?
At the moment, I can place patients on ventilators with a viral filter but I cannot use cpap because of a local ban on unfiltered positive pressure setups. Do you think the following setup would be both feasible for most of us to use in the ED and also be low or very low risk of aerosol? Based on bubble CPAP setup previously seen in kids (with modifications #3-4 and that in #7 the water column is a little higher pressure than the popoff valve) Setup materials (in order): 1. Medical air and/or oxygen outlet that will be set to… Read more »
fish aquarium bubble diffusiion and hose control systems might work, maybe gravel and filters and all the rest of the hardware caps and filters… get an aquarium? “THAT I ALREADY HAVE THE SUPPLIES TO TRY” well said.
1/2 inch pvc schedule 40 plumbing pipe fits into medical beathing hose and also tightly into a standard blow molded soft drinks bottles, could be either/or HF or CPAP/PEEP depending on how tight the nasal holes connection becomes accidentally or on purpose. . Full size medical hose passing moustache under the nose to the bubbler is least rebreathing option as per https://fn.bmj.com/content/early/2020/02/11/archdischild-2019-318073 Passing the exhale hose thru a wall to outside, or moving all operations outside as was done in Ebola field hospitals seems the order of the day as this pandemic is disproportionately deadly or disruptive to health care… Read more »
“Interestingly, during the outbreak of SARS in Guangzhou, clinicians kept the windows of patient rooms open and well ventilated and these may well have reduced virus survival and this reduced nosocomial transmission. SARS CoV can retain its infectivity up to 2 weeks at low temperature and low humidity environment, which might facilitate the virus transmission in community as in Hong Kong which locates in subtropical area (Table 2(e)). Other environmental factors including wind velocity, daily sunlight, and air pressure, had shown to be associated with SARS epidemic, should also be considered [16, 17].”
https://www.hindawi.com/journals/av/2011/734690/
Dr. Weingart,
What are the thoughts with BiPaP, thinking based on some of the data with pressure support BiPaP might be better. Listening to your wee think the data is playing out to this being the correct tx using CPAP and high flow NC. Thinking the BiPaP would provide better support, thoughts and if so where would one start for settings basing this on it provides better pressure support, which seems to lead to better outcome if they are vented using pressure support, not that the data has really great outcomes from being vented.
My hypothesis as to why these patients are relatively well-looking while being profoundly hypoxemic is that perhaps the oxygen/hemoglobin dissociation curve has time to shift right and offload more oxygen to peripheral tissues. Perhaps this is happening Thus, the profound hypoxemia without lactic acidosis.
Great cast, thank you. Intriguing parallels to hape. I suspect that early tube enthusiasm can be further tempered by a podcast on how to cheaply set up a negative pressure room and/ or how to set up exhaust systems for cpap/ hfnc that suck up aerosolized virus. Keep up the great work!!!
We should consider old fashioned things that we have forgotten.
The percussion and postural drainage protocols we use to our Cystic Fibrosis patients could be very helpful in staving off intubation.
I would suggest that for our patients who we are keeping at home we should recommend 2 pulmonary exercises.
1) Incentive spirometry. We use post operatively, but also with my pulmonary cripple VA patients I have found it is great for pulmonary Pre-Hab before surgery.
2) Cystic Fibrosis percussion and postural drainage protocols by family members. Here is an information sheet from CFF
https://www.cff.org/PDF-Archive/Introduction-to-Postural-Drainage-and-Pecussion/
We could pre-Hab the public at large. Or at least those coming to testing centers.
Thanks for the helpful podcasts. Get your “bottle head” ventilator here: https://www.sea-long.com/
“This was the first experimental study to evaluate the individual effects of VT, PEEP, plateau pressure (Pplat) and ∆P on lung inflammation, fibrogenic response, endothelial and epithelial cell injury, and activation of cell stress. Ventilation with low VT and low PEEP was associated with greater atelectasis, while increased VT and low PEEP reduced the amount of atelectasis and low VT and higher PEEP promoted a progressive increase in hyperinflation, to similar degrees as with high VT with low PEEP.” i guess this is slightly blasphemous but seems explained well in review paper, maybe has a relevance in this pages quandary.… Read more »
https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-1991-3
oops I made the whole post a link above by mistake, this is the blasphemy paper
“A ventilatory strategy that leaves as much lung derecruited as possible, so that gas exchange is still adequate and opening and closing of collapsed alveoli is avoided”
most innovation is the overturning of a preexisting idea? in the above study blashphemy
“even 15 cmH2O PEEP has been shown not to be enough to keep the lung open [47] and to be associated with overdistension”
Here is a simple non aerosol-izing Cpap design that can does not rely on filters and be rapidly assembled from common available materiels. And might be allowed in hospital operations. I cant really post pictures and too much noise on this wonderful post, here is a link https://www.facebook.com/phrahnsis.musecal look for pictures with manikin. What post says: “A walking constant negative pressure Cpap that does not aerosolize virus as might unfiltered sleep Cpap that are not allowed in many hospitals/areas. Based on vacuum cleaner up tween cheeks into box frame, trash bag, and a water manometer. All these schemes are potentially… Read more »
I have read an article that describes the virus binds to Haem and affects oxygen and CO2 binding.. Is the hypoxia a haem issue and not related to pulmonary disease and they just need oxygen. And there is a second batch that end up with pulmonary injury. Two patterns?????
https://chemrxiv.org/articles/COVID-19_Disease_ORF8_and_Surface_Glycoprotein_Inhibit_Heme_Metabolism_by_Binding_to_Porphyrin/11938173
is this the paper ?
Thank you so much for your thoughts. As an ER doc i recently got infected by corona. And i really would like to add something from the patient experience. Everybody is talking about being prone and that really helps a bit, but for me it was the most helpfull to stay upright. During 3 nights i slept with my body studded upright. If i didn’t do this is could not manage but after 20 minuter uprights i felt a real releave. Still sick as a dog but manageable. I have been asking around with other patients and heard this more… Read more »
thanks for that front lines tip!!!!
Arona Ackermann. Not a doctor. I have not tested positive for Covid. I live in Dallas. About 3 weeks ago I had the feeling of cotton in my upper airway. In the back of my throat. It causes anxiety and the overwhelming feeling I wouldn’t be able to keep breathing because of the focus it took. I had a cough but it wouldn’t help. I could not sleep. When i would try I would feel like I was breathing through a tube deep in the ocean. If I did drift off I’d wake up in a panic the second i… Read more »
This from an Italian group seems to contradict a lot of what is being said in this Wee and on this site. Thoughts?
Gattinoni, L., S. Coppola, M. Cressoni, M. Busana and D. Chiumello (2020). “Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome.” Am J Respir Crit Care Med.
https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE
read this last night when 1st published. i did not see a single contradiction. what contradictions are you seeing
Seems like the dogma has been high PEEP right out of the gate and proning and positioning are super important. These guys seem to be saying that low PEEP is better and positioning is less important. Maybe I’m not reading it correctly but it seems like they are advocating for a more “gentle” approach – whatever that means.
can’t speak to the dogma. Our entire conversation on this wee was to avoid high pressures of mechanical ventilation entirely by not intubating. I also have been advocating high (1.0) fiO2 in all high compliance pts to limit iatrogenic peep
Any concern for absorption atelectasis in the awake person on 1.0 FiO2? I would be concerned it may can an increase in shunt. Are you getting patients to do frequent “self recruitment”?
If this disease’s effect on the lungs mimics HAPE, is there a role for Viagra?
As optimal treatment strategies change from early intubation to Hi Flo and CPAP, are the policy makers aware of this? There is a limited supply of these also,, so will need to increase production of these, not just ventilators.
Thank you for this podcast. Just what I needed to hear. Last week I knee jerk intubated someone and suddenly couldn’t oxygenate them as well as they were oxygenating themselves. This week After listening to your podcast I took someone from 70% with moderate Resp. distress On a NRB to 98% by asking them to prone themselves. Even after my intensivist had them go back to supine (he wasn’t convinced that probing was an option for awake patients) and they dropped to 75-85% they did not go back into respiratory distress and looked great despite that low number. Definitely not… Read more »
In light of the dismal survival rates for our elderly covid pneumonia patients requiring mechanical ventilation, why is there not more of a push to avoid intubation and focus on palliative care for this patient population?
I love the idea of not reflexively intubating these patients out of fear and treating them clinically. We see people with SpO2 in the 80’s mountaineering (less than 20,000 feet) on a regular basis that are not seeing end-organ damage due to their hypoxia.
My concern with CPAP and HFNC is the aerosolization risk. Does anyone have any data on this?
It doesn’t sound like a capillary leakage problem but something going on with the hemoglobin. The hypoxia readings sound like they are falsely low, like what can occur with hemoglobinopathies and met hemoglobin. Is there any lactic acidosis going on or multiple organ failure? If high oxygen is delivered to lungs when there is not sufficient hgb to pick it up, it can cause damaging free radicals to happen. Have you look at co- oximetry to see if there is reduced hgb levels and are there signs of hgb breakdown in the blood?
It’s curious that the virus attacks beta haem molecule of hgb. Beta thalassemia is genetic condition most common in Mediterranean region and also in Asia. In addition Italians are largest ethnic group in NYC. These are the same areas that are getting hit hardest. Has anyone noticed any ethnic disparities with this virus.
We are only thinking on the lung!! Maybe the problem it’s also in the haemoglobin!!
Airway edema? Much gratitude for the leadership in this chaotic mess. Avoiding intubation when feasible makes so much sense. Question – given the anecdotal reports of upper airway edema in some COVID patients… are a proportion of the patients failing simply because of this additional perturbation? Clearly this is a fraction of the cases that fail noninvasive methods. Other mechanisms like widespread thrombosis including at the level of the alveolar membrane, hemoglobinopathy-like state, dysregulated hypoxic vasoconstriction etc etc in play. But again, if the additional factor contributing to deterioration is predomenately subtotal upper airway occlusion – does it make sense… Read more »