There has been considerable speculation in the literature regarding the physiology of intubated patients with COVID, but little actual data. A fresh study describing the physiology of intubated patients at Massachusetts General Hospital and Beth Israel offers to finally answer some questions. This is a retrospective case series involving 66 patients intubated during March 11-30. […]
Search Results for: aprv
COVID 19 ICU/stepdown management
CONTENTS: Management of COVID-19 patients admitted to stepdown or ICU Link to full chapter here (more complete – but longer). Preamble & caveats Initial tests to guide management Organ support Cardiovascular Respiratory Noninvasive respiratory support Invasive mechanical ventilation Infectious disease – antibiotics Renal Hematology Neurology Immunomodulation Steroid Tocilizumab Baricitinib Things that don’t work Remdesivir Convalescent […]
PulmCrit: Fighting refractory ARDS with physiologic jujitsu
Jui-jitsu is a Japanese martial art based on flexibility and technique, rather than a directly confronting an opponent with force. In the spirit of jui-jitsu, this post explores how to support ARDS patients without directly confronting lung dysfunction. This is useful in refractory ARDS, when frontal assault has failed.
EMCrit 365 – Setting PEEP and Righting the Right Ventricle in ARDS with Matt Siuba
Setting PEEP and Righting the RV in ARDS with Matt Siuba
COVID 19 Complete Chapter
CONTENTS Basic biology Infection control Transmission Personal protective equipment (PPE) Diagnosis Signs & symptoms Labs Imaging CXR & CT scan Lung ultrasonography General approach to imaging Bronchoscopy Diagnostic approach for admitted patients Treatment: General protocols ED patients getting admitted to the hospital Inpatient management of hypoxemic, non-intubated patients Intubated patients Treatment: Specific anti-viral & immunosuppressive […]
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 […]
EMCrit 329 – Bariatric Critical Care and Resus Ready for the Super Obese Patient
We need to be ready to resuscitate any patient that comes to our EDs and ICUs. Being Resus Ready for bariatric patients requires forethought and planning. Let’s discuss some resuscitation strategies for the obese patient.
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 […]
EMCrit 124 – The Logistics of Proning for ARDS
Proning is one of the only evidence-based techniques to affect the mortality of ARDS patients. I’ve been wanting to do an episode on proning for a while.
PulmCrit Table of Contents (TOC)
TOPICS airway & procedures cardiology endocrinology gastroenterology hematology/oncology infectious diseases nephrology neurology pulmonology rheumatology toxicology methodology & miscellaneous Airway pharmacology Medication sequence: rocketamine vs. keturonium Ketamine-tolerant patient Catastrophic complications, ROC vs. SUX Arterial lines: wrist versus the groin? Cricothyrotomy in asphyxial cardiac arrest Difficult airway communication via allergy list Drowned airway Large-bore suction strategies & […]
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 […]
Apneic ventilation using pressure-limited ventilation
Introduction 0 Noninvasive ventilation (i.e. BiPAP) is arguably the most powerful approach to optimize oxygenation and ventilation before intubation, given its ability to provide 100% FiO2, PEEP, and ventilatory support. The only way to improve upon this is to extend the administration of positive pressure ventilation throughout sedation and paralysis, right up until the moment […]
PulmCrit- Rigorous vs. lenient spontaneous breathing trials: The answer at last?
background There has long been debate about exactly how to design a spontaneous breathing trial. If the trial is made too easy, then patients would be extubated before being ready (leading to re-intubation). Alternatively, if the trial is too hard, that would prolong mechanical ventilation beyond the point of being beneficial. The figure above shows […]
Liberation from the ventilator
CONTENTS Rapid Reference: Optimization & items to consider prior to extubation 🚀 Spontaneous Breathing Trial (SBT) If the patient fails the SBT Causes of failed SBT Investigation If the patient passes the SBT A trial of extubation Post-extubation support Timing of tracheostomy Some additional concepts Unplanned extubation Nocturnal extubation Understanding & navigating the obesity quagmire […]
Atelectasis
CONTENTS Basics Clinical presentation Types and causes of atelectasis Radiology Right upper lobe Right middle lobe Right middle lobe syndrome Left upper lobe Lower lobe atelectasis Bronchoscopy Management Additional/related topics Round atelectasis Drowned lung Questions & discussion abbreviations used in the pulmonary section: 6 ABPA: Allergic bronchopulmonary aspergillosis 📖 AE-ILD: Acute exacerbation of ILD 📖 […]
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