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.
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.
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:
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.
COVID POCUS DATA
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:
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).
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.
So a lot of people have been asking for a VExUS tutorial, and since our paper was just accepted, I figured it’s a pretty good time to do it! Thanks to Dr. Ian Ajmo of FrancoFoam fame who put on his Hollywood director’s hat and filmed it!
Here is the classification that has been validated:
I’m attaching our chapter on venous congestion below as well.
Of course, Andre Denault, William Beaubien Souligny, Rory Spiegel, Korbin Haycock and myself will be running VExUS workshops at H&R2020. There aren’t many spots left!