APRV & COVID Respiratory Failure with Spiegel & Farkas. #FOAMed, #FOAMcc

So at our last webinar (still to be edited due to an unfortunate trolling event), we briefly touched on modes of ventilation but really didn’t delve into it very deeply, so, being fortunate enough to know some really smart people, I figured I might gather up these two for a quick chat. They are both known for no-nonsense, out-of-the-box thinking, paired with solid physiological thinking, which in my mind is the only way to approach complex problems and system failure. Plus, with Rory (@EMnerd) and his powerful nihilistic approach, there would be no chance for a whimsical approach, it would have to have a base in physiology, evidence (bedside or literature) or both!

So just as a little brain teaser, I would like anyone reading to think about how many severe respiratory failure syndromes they are aware of that attack the lungs in a predictable volumetric fashion, where one can say, for instance, that consistently, X% of the parenchyma is affected. Kinda hard, huh? Yet, if asked how best to ventilate these patients, most of us who feel we have a good grasp of severe respiratory failure would answer without thinking twice: “lung protective ventilation: good peep and 4-6 ml/kg.” In a lear, confident tone, most likely as well.

Now I would say that only the first part is correct: lung protective ventilation. As to the second part, it would, to me, only hold true with uniform pathology and uniform patients. But I’ll let Rory rant about that himself, it’s far more entertaining!

So here is our chat.

Hope everyone gets something out of it!

 

cheers

 

Philippe

Re-Thinking the Early Intubation Paradigm of COVID-19: Time to Change Gears? #FOAMed#CO

So we wrote this up last week, but the (relatively) slow process of submission made us decide to just go ahead and release it as pure #FOAMed literature, because while highly relevant and somewhat controversial 10 days ago, it is now almost already accepted!  What an incredible (in all senses of the word) time we are in…

So here are our thoughts:

 

I think it is important to clarify that none of us are saying that ventilators should NOT be used. HFNC or NIV approaches will not avoid intubation and mechanical ventilation for all patients, only for some, and for those it doesn’t, mechanical ventilation is an absolute life-saver. For many laypeople and perhaps non-critical care or acute care physicians, this may have been lost in much of the social media discussion…

For anyone interested in the development of the CAB-RSS score, do get in touch, we are in the process of an inter-observer validity study and eventually will integrate in a decision making algorithm.

 

cheers

 

Philippe

COVID-19 Webinar: Respiratory Management #FOAMed #FOAMcc

 

So I had an awesome time talking and learning from some of the smartest and most progressive thinkers I know, some of the usual suspects at H&R, and some amazing docs from Italy and NYC who are at the front lines of this COVID war.

Programme

  • HFNC & NIV – do we dare use them? 
  • when do we intubate?
  • how do we ventilate? prone ventilation routine or rescue?
  • Adjuncts: suction, bronchoscopy
  • When do we wean?
  • Q&A if time allows.

Panelists:

Dr. Laura V. Duggan MD FRCPC (Anesthesiology and Pediatrics), Associate Professor, Department of Anesthesiology and Pain Medicine, University of Ottawa, Canada @drlauraduggan. www.airwaycollaboration.org

Dr. Marco Garrone, MD, ED doc from Mauriziano Ospedale, Torino, Italy. @drmarcogarrone.

Dr. Cameron Kyle-Sidell, MD, ED-ICU, Maimonides Hospital, New York. @cameronks

Dr. Josh Farkas, ICU, University of Vermont, Creator, The Internet Book of Critical Care (IBCC), @pulmcrit.

Dr. Adam Thomas, ED doc & CC Fellow, University of British Columbia, co-author, The Internet Book of Critical Care, @adamdavidthomas.

Dr. Philippe Rola, ICU, Santa Cabrini Hospital, Montreal, Quebec. @thinkingcc

Dr. Rory Spiegel, ED-CC doc, Washington Hospital Center, Washington, DC. @emnerd

Dr. Scott Weingart, ED-CC doc, Creator, EmCrit.org, Stony Brook Hospital, New York. @emcrit

Here is the audio, am working on editing the video and should have it up soon.

I realize many questions came from the audience regarding L and H phenotypes, a concept which was rapidly assimilated by those reading and discussing day and night to stay at the cutting edge of the understanding of COVID physiology, so I am including the Gattinoni paper which is the source. For those still thinking of this as ARDS, understand that the single most published author and pre-eminent authority on that disorder states “this is not ARDS,” even if the H type, for those who progress to it – or evolve towards it due to initial management strategies, is fairly similar.

Gattinoni COVID

A huge thanks again to my all star cast for making this happen and for their continuing efforts to learn and teach. Please refer to Josh and Adam’s IBCC covid page which is constantly evolving, and Scott’s emcrit.org for ongoing info.

Webinar Audio:

 

Webinar video

 

There were a lot of comments and questions, many very interesting, will try to address them in the next webinar likely in a week or so.

 

cheers and stay safe

 

Philippe

COVID-19 – Respiratory Management: A Physiological Approach. #FOAMed, #FOAMcc, #COVID19

Hi,

So we’ve got a pretty good lineup of docs who have been taking care of COVID patients for the last few weeks assembled, including one who had pretty much seen it all from the Italian battlefront. We’ve got anaesthesia, critical care and emergency medicine representatives. As usual, we’ll be trying to bring highly physiological and practical approaches to managing the respiratory failure of this new disease we are all facing.

So this is #FOAMed, but I just found out that the max meeting size is 500. So I guess it is first come first served. Asking everyone who is not a panelist to stay muted please, those not adhering to this will be promptly booted out as it completely ruins audio quality. It should be recorded if the cloud doesn’t fail and will be available on this blog.

Questions can be sent on twitter to @ross_prager who will set us up, please use #thinkingcovid.

Join the Webinar here!

Programme

8pm EDT (GMT-4) Welcome panelists & intro

  • HFNC & NIV – do we dare use them? 
  • when do we intubate?
  • how do we ventilate? prone ventilation routine or rescue?
  • Adjuncts: suction, bronchoscopy
  • When do we wean?
  • Q&A if time allows.

Panelists:

Dr. Laura V. Duggan MD FRCPC (Anesthesiology and Pediatrics), Associate Professor, Department of Anesthesiology and Pain Medicine, University of Ottawa, Canada @drlauraduggan. www.airwaycollaboration.org

Dr. Marco Garrone, MD, ED doc from Mauriziano Ospedale, Torino, Italy. @drmarcogarrone.

Dr. Cameron Kyle-Sidell, MD, ED-ICU, Maimonides Hospital, New York. @cameronks

Dr. Josh Farkas, ICU, University of Vermont, Creator, The Internet Book of Critical Care (IBCC), @pulmcrit.

Dr. Adam Thomas, ED doc & CC Fellow, University of British Columbia, co-author, The Internet Book of Critical Care, @adamdavidthomas.

Dr. Philippe Rola, ICU, Santa Cabrini Hospital, Montreal, Quebec. @thinkingcc

Dr. Segun Olusanya, Anaesthesia-ICU, Reading, England. @iceman_ex

Dr. Rory Spiegel, ED-CC doc, Washington Hospital Center, Washington, DC. @emnerd

Dr. Scott Weingart, ED-CC doc, Creator, EmCrit.org, Stony Brook Hospital, New York. @emcrit

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

 

Philippe

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

 

Philippe