COVID Clinical Discussion w/Cameron Kyle-Sidell: NYC ED/ICU doc in the trenches. #FOAMed

Dr. Cameron Kyle-Sidell is an ED-ICU Doc at Maimonides in New York, currently under the COVID fire. He put up an inflammatory tweet yesterday which caused a lot of different reactions, because it clearly challenged the widespread even if only recent belief that one should intubate the COVID patients quite early, usually much earlier than one would in typical respiratory failure:

So here you go:


Please share your thoughts and experiences – my comments in bold!

Korbin Haycock:

Very interesting. My experience is zero cases so far with COVID-19. Just some thoughts for what it’s worth from someone with no experience with COVID: Hypoxia is due to V/Q mismatch, diffusion, hypoventilation, low pO2 (altitude), shunt, low cardiac output (as more O2 is extracted off HgB and mixed venous O2 is low), and finally hemoglobin problems (whether by poisoning or defective HgB).

It was pointed out to me by Brett Berliner tonight in a paper (via twitter) that SARS CoV-2 appears to disrupt the beta chain of HgB to take up O2. I’d never heard of this, but if this is the case, exchange transfusion makes sense as a therapy for hypoxia as long as one is past the stage of illness where the viral levels are low. If this is a hemoglobinopathy, no amount of increase in mean airway pressure or FiO2 will fix the hypoxia.

Perhaps people out there with actual experience with COVID-19 can shed additional light on how the hypoxia tends to respond to positive pressure or increases in FiO2, or more importantly a lack of expected response, that would indicate the mechanism of hypoxia (such as a hemoglobinopathy).

It is very interesting that the hypoxic patients described in the post don’t appear to be very symptomatic in terms of SOB, nor do they attempt to compensate for the ding to DO2 from low O2 sats (O2 content) with an increase in HR to drive up CO. Normally DO2/VO2 ratios are around 4-5, so either the illness suppresses the normal physiological response to a decrease in the ratio, or the VO2 is suppressed somehow (seems unlikely). In any event, perhaps we should revisit the idea to intubate early if hypoxic, unless the patient actually looks really bad.

Summer Allen:

I’m Pulm/cc. This was fascinating and sparked some ideas. But, I need someone smarter than me to take it forward. The first thought is this is not what we know. It’s a different beast. Stop trying to make it fit what we know.

Why are people not short of breath or tachycardic? I suspect most of this is that compliance is high and there is no issue with expiratory flow limitation, hence WOB is more or less normal… And once hypoxia is corrected with O2, they feel fine.

Does the virus hide hypoxia from the body? Maybe it turns off normal feedback that would make us short of breath and tachycardic. The body doesn’t compensate because it doesn’t know it’s hypoxic. That’s why people are being found dead at home because they didn’t know they were slowly suffocating. Maybe it’s not affecting kids because their feedback mechanisms are more heightened already because of growth. Trying to think outside of the box after listening to this. I definitely agree that treating these patients like normal pneumonia with vent/pressors/fluids isn’t the answer.


Bala Totapally

Looks like these pts have severe V/Q mismatch without abnormalities in respiratory mechanics. Almost like a cyanotic heart condition. I agree if the mechanics are not worsening we may not achieve a lot by early intubation except to prevent sudden deterioration, if anything. HFNC with 100% will be the right choice. Has anyone tried nitric oxide before intubation? Might work to improve V/Q mismatch and reduce RV strain.

I am definitely planning to look at RV function and use inhaled vasodilators both for the VQ and for RV function. 

Richard Harper:

Great talk and very fascinating points. Short of hyperbaric chambers for everyone, I think keeping everyone on high flow for as long as possible seems very reasonable. Given the ongoing reports I’m seeing regarding the pathophysiology regarding COVID-19 related lung disease, including your shared observations, it seems like using stress index on intubated patients would be the best measure of appropriate PEEP in this setting without “trashing” the lungs. If our understanding is correct regarding the atelectatic, high compliance Sars-cov-2 lung is correct, then the PEEP table is not going to accurately predict the proper settings and the stress index measured once a day would solve the problem of too much PEEP.


stay safe!



COVID Clinical Discussions: An Update w Dr. Garrone. Sharing CPAP??? #FOAMed

Incredible discussion with front-line italian ED doc Marco Garrone (@drmarcogarrone – follow him on twitter for great covid POCUS cases). Chilling for those of us not yet in the storm, but very interesting stuff, especially the use of NIV-sharing – two patients simultaneously on CPAP.

Here is the audio:


For more on vent sharing and references, please see Josh’s post here!

stay safe



COVID-19 Clinical Discussions – Dr. Blair Schwartz. #FOAMed

Tonight I had a chance to chat with Dr. Blair Schwartz, intensivist at the Jewish General Hospital in Montreal, Canada, one of the ministry-designated COVID centers, in part due to their ICU which was designed with pandemics in mind and able to physically be divided in sealed-off halves. Impressive stuff.

Here is our chat:

So thus far, the small Montreal experience parallels what we have heard from the Chinese and Italian experiences: they crash fast, so intubate them early, then deal with a high compliance ARDS that is difficult to oxygenate, and prone them. Oh yeah and the critically ill are not the very elderly at least so far…

Oh yes and I also questioned Blair on whether they were re-using N95s or staying completely protected for the day – seems to have been a practice in some of the dedicated areas in China, but so far, given “only” 3 patients they are keeping the general unit “clean” and disposing of all PPE between patients.

We’ll keep tabs on the evolution of the critically ill cases and try to share anything useful.

Here are my other COVID links: POCUS & COVID and Clinical Discussions.

Scott has a great video on COVID preox here:

And if you are running out of vents be sure to check out Josh Farkas’s post here on increasing your patient to ventilator ratio!

Jonny Wilkinson’s fantastic COVID page.


wash your hands & stay safe




POCUS and COVID: Practical & Clinical Applications. #FOAMed

So I’ve yet to take care of any COVID patients, but we are ramping up, and it’s just a matter of time. In the meantime, practical issues such as where we will cohort patients and how we protect non-COVID patients and HCPs are happening, and one of the challenges in infection control is imaging, which is a staple of severe respiratory illness.

Evidence has been steadily coming out that lung ultrasound is carving itself a pivotal role in the diagnosis and management of COVID infection. Here are some of the things I’ve gathered and I think are worth sharing. I will be adding to this as I collect from others and eventually generate a COVID POCUS database and experience.

a. Lung US is more sensitive than CXR for interstitial patterns, small effusions and subpleural thickening. 

b. COVID seems to have some particular ultrasound features:


Full article: COVID LUS

c. POCUS can be used to detect worsening or improvement of disease – by personal communication of Italian and Chinese ER/ICU docs. No published data yet, but several self-scanning infected physicians corroborate clinical improvement with resolution of POCUS lung findings.

d. POCUS can also detect the usual pathologies!  Pneumothorax is not a rare occurence in ventilated patients, and there may be an increased rate related to the parenchymal damage resulting in the unusually high compliance respiratory failure.



Here is a good example from Marco Garrone with COVID B line pattern on the left, along with pleural thickening and small sub-pleural consolidations, note also the clustering of B lines, compared to the left, B lines of CHF with a relatively smooth and even pleural line:

This is a great article by Yi et al, a Chinese radiology group, with some great CT/POCUS comparative images:

LUS covid study



This makes it important that all physicians and probably also PAs and nurses pick up basic LUS skills. At our shop we are making sure all first line providers can screen for lung POCUS abnormalities.



Lung ultrasound modules have been made open access at USABCD!

here are some excellent first steps by Jacob Avila:

How I perform the Lung Ultrasound Exam

B Lines




COVID-19 Clinical Discussions with Dr. Marco Garrone & Dr. Peng Zhiyong. #FOAMed

COVID19 has made for a rough start to 2020 for humans. Now ramping up in Canada, we can only hope that lessons learnt in China and Italy by governments and medical teams can be applied in a timely enough fashion to flatten the curve and allow our already stretched-thin healthcare system to absorb it without dire consequences for both COVID and non-COVID patients.

At my shop we have started our (re)organizational plan for the potential storm that may hit us.

So here is my chat with Marco (@drmarcogarrone)

And here is the vidconf audio with Dr. Zhiyong


I apologize for the prolonged ending there were technical difficulties and we ended up losing Dr. Zhiyong’s connection at the end.

Some clinical points from these and other discussions:

high compliance ARDS

– needs peep, but avoid hi peep as seems to have high risk of pneumothorax. This may make sense given high compliance may reflect alveolar wall elastic fiber damage.

avoid NIV including HFNC unless negative pressure room to prevent aerosolization.

may need to use N95 for entire duration of rounds in hot zone ICU to save stock

– personally, I would/will consider early proning or modified proning for spontaneously breathing patients (not on NIV either, just face mask).

LUS for screening dx and f/u (see below)


Other COVID resources:

Splitting ventilators for multiple patients

Covid effects on cardiovascular system

Chinese experience with LUS:

My friend Jonny Wilkinson (@wilkinsonjonny) put together a great page with a ton of resources here at criticalcarenorthhampton.

My EMCrit Teammates Josh and Scott have put together some great clinical points as well, especially some practical tips for respiratory support setups and airway management.

IBCC a super comprehensive chapter on COVID.

EMCRIT on airway management.

And here are some excellent documents on hospital preparedness, ethics, a ventilatory support infographic from our italian colleagues as well as some kindly shared clinical notes and tips.


italian_triage_ethics (1)

ESICM info

SIAARTI – Covid-19 – Airway Management rev.1.1

COVID notes March 11 (1)

Also, as this will undoubtedly be a time for stress for HCPs caring for COVID patients, a respirologist friend of mine shared a link to a wellness/meditation tool, the coronavirus survival guide which has been made freely available to us. Now I have not tried it yet but I trust Andy.

Comment from anaesthetist Dr. Marco Vergone who is on the front line in Turin, Italy:

We are using prone positioning in almost all of our patients that require invasive mechanical ventilation, we’re trying alternate lateral position for patients on CPAP (helmet), and personally I find very promising prone positioning for patients in spontaneous breathing during weaning from CPAP, before discharge from the ICU.
I can confirm that diagnostic (CT and XR) is really burdensome when you have many isolated ICU patients, so lung US becomes paramount for bedside daily evaluation.
We’re working on standardized protocols for different levels of expertise of colleagus (pro level, basic skills, beginners).
For intubation procedures, we perform rapid sequence with ketamine + rocuronium or fentanil+propofol+rocuronium and ALWAYS videolaryngoscope. We always clamp the tube before disconnections and we always sop gas flow before removing helmets of masks. Apart from correct use of PPE, it is paramount to reduce aerosolization and contamination of the environment.
Get prepared ASAP, and stay strong!
Best, M

hope some of this can help other HCPs in these trying times.