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.
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.
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.
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.
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.
Here Marco tells us more about the evolution of clinical management and hospital transformation from his now COVID-Hospital. He tells us about the now 8 patients who – by necessity – have had to share NIV with a fellow patient.
Interesting and chilling for those of us for whom the wave hasn’t truly hit yet…
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.
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.