Discover and read the best of Twitter Threads about #ards

Most recents (24)

I would love to have a drug to give #COVID-19 patients with #ARDS to reduce their mortaily by 1/3. Dexamethasone might be it, but there are important reasons to be skeptical of press-release-based medicine and demand we see the whole RECOVERY study out of the NHS. (THREAD 1/8)
There are other viral pneumonias besides COVID-19. Studies of steroid use during H1N1 showed either no effect or potential harm. Obviously, COVID-19 is not influenza, but it’s reasonable to think there might be similarities across viral pneumonias (2/8)

ccforum.biomedcentral.com/articles/10.11…
Yes, many were observational studies with confounding. But with additional studies trying to account for this still suggesting possible harm, intensivists have had enough reason to avoid steroids in viral pneumonia absent another reason (eg asthma). (3/8)

atsjournals.org/doi/full/10.11…
Read 8 tweets
Mengenai paru basah, sampe sekarang saya gak ngerti ini merujuk ke penyakit paru yg mana.

Paling mungkin ada 3 kondisi, dgn gejala & penyakit penyebabnya secara umum beda:

(1) efusi pleura: sesak, nyeri. Bisa krn #TB, #tumorparu, atau gagal ginjal
(2) pneumonia: radang paru akibat infeksi selain #TB. Sesak, demam, batuk.
(3) gangguan napas berat akut #ARDS: bisa krn infeksi berat mis. #COVID19, paru orang tenggelam, keracunan gas, dsb.
Read 5 tweets
Supposedly, #COVID19 patients who are put on a ventilator do terribly and are very likely to die. You’ve probably seen the headlines with 88% mortality.

A #tweetorial on the actual mortality of #COVID19 on the #ICU

independent.co.uk/news/world/ame…
Before we start, consider the “normal” mortality rate for a patient with acute respiratory failure on the ICU. Probably the best study to assess that is LUNG-SAFE. 50 countries. 4499 pt with ARF. 3022 #ARDS. ICU mortality = 34%.

jamanetwork.com/journals/jama/…
To the data! Remember that NY cohort in @JAMA_current; mortality was actually 24.5% at that point. The remaining patients were just not discharged! Just means that dying is quicker than surviving. So mortality is anywhere between 24.5% and 80%..
jamanetwork.com/journals/jama/…
Read 9 tweets
The promised #Tweetorial on validation of #COVIDー19 phenotypes that we published @AnnalsATS

But before we start.

Disclosures:
- I'm a splitter and 💕 phenotypes
- If physiology can teach us; I'm all for it!
- But, data and physiology should converge

What we know:
- #ARDS can be split into #phenotypes
- But, uncertain therapeutic implications



- #COVID-19 might be split into phenotypes as well
- But, ☝️based on #physiology with little data to back it up.
Remember:
- H phenotype = ⬆️elastance (=⬇️compliance) + ⬆️ lung weight + ⬆️shunt + ⬆️recruitability. What we consider ARDS.
- L phenotype is opposite - not resembling most ARDS cases.. Would not benefit ⬆️PEEP, ⬆️TV?

Lung morphology is explained here:
Read 9 tweets
1/Notes from the #COVID19 plateau:
2/In #Washington the total number of #COVID19 cases is down from the peak but not very far. In the hospital, it feels steady. Plenty of capacity for more if we need it. Thankfully, public health efforts and clinical surge planning prevented us from running out of beds.
3/I knew we were likely to have a long course, but I didn’t expect it to be this tiring. It feels like treading water. The surge wasn’t as big here, so the current levels don’t seem like a relief.
Read 10 tweets
The past few days have included a lot of thoughtful debate/discussion about #COVID19 and #ARDS, some snark (of which I too am guilty), and a hefty dose of HOW DARE YOU CHALLENGE A MASTER, YOUR RIGIDITY IS KILLING PEOPLE. I have a few things to say. Bear with me as I ramble a bit.
The idea that #EvidenceBasedMedicine does not allow for individualization for specific patients and changes in their clinical courses is a fallacy. Certain concepts that are known to save lives can & should be adhered to in a manner that is appropriate for the individual patient.
I thought this was obvious but that clearly is not everyone’s interpretation of #EBM. Also lung-protective ventilation does not = set it and forget it. Settings needed to maintain LPV will obviously change during a patient's course, something that experienced clinicians know.
Read 13 tweets
Some #COVIDDeepThoughts / reflections on clinical care in the #COVID #ICU now that I’ve had a chance to slow down a bit. It seems like a lot of folks are reaching for explanations for why #COVID19-related respiratory failure is something different & exotic & somehow not #ARDS.
As a result, a lot of pretty out there treatments with significant risks and downsides associated with them are being suggested by physicians, many of whom did not regularly care for #ARDS patients pre-#COVID19. These are being hyped up in the press & families are asking for them
I get it, it’s a lot less exciting to say “the patient recovered from #COVID19 w/ meticulous supportive #ARDS care” than it is to say “I did this weird new thing or gave this specific drug & the patient miraculously got better.” But #fundamentals >>> hype & unproven therapies
Read 8 tweets
1/n Some nuances with #COVID19 #criticalcare. They are the exception
👉🏼Permissive Hypoxemia
😨BiPAP, HFNO, prone sleeping, control fever
👉🏼VT: 6mg/Kg IBW - ARMA
👉🏼Stent the lung: High PEEP table ARDSnet
👉🏼Prone: P/F <150 -PROSEVA
👉🏼Dry lungs: limit fluids, diurese - FACTT Image
👉🏼CAM-ICU: Pain, agitation, delirium assessment, minimize sedation, limit propofol (PRIS)
👉🏼Wake up and Breathe: SAT daily - ABC Trial, SBT PS 5/5
👉🏼Remove lines
👉🏼PUD prophylaxis
👉🏼DVT prophylaxis Image
3/n. If you haven’t seen this video from Dave Janz in New Orleans. It’s a good one on #criticalcare in #COVID19
Read 5 tweets
Interesting issue in mechanical ventilation of #COVID19 patients, each one here after >10 days of mechanical ventilation.

How might we monitor for development of this? Time to pay attention to resistance, oft neglected in the age of COVID #ARDS...

#tweetorial #SoMe4MV
First step is to examine the flow waveform. In this case a patient in volume control, to observe how passive expiration is changed by changing time constant.

More on time constants here: derangedphysiology.com/main/cicm-prim…
A faster time constant is associated with decreased compliance (increased elastic recoil). The opposite is seen with airway resistance.

In these cases we often see the expiratory phase on the flow diagram *not* return to baseline before the next inspiration is initiated
Read 9 tweets
Lots of talk about funny hemoglobin and ‘happy hypoxic’ people with #COVID19. I think we can explain everything using plain old pulmonary physiology. Let’s dive into hypoxic pulmonary vasoconstriction (HPV) and hypoxic ventilatory drive (HVD) and try to make sense of this...
1/
Normally, different areas of the lung receive different amounts of ventilation. The lungs are able to sense oxygen levels and adjust smooth muscle tone to modulate blood flow. This process is hypoxic pulmonary vasoconstriction (HPV), reviewed here: ncbi.nlm.nih.gov/pmc/articles/P…
2/
To understand why HPV is important, imagine a simple two alveoli model of the lung. Normally oxygen content (CaO2) and saturation (SpO2) increase as blood crosses the alveolar capillaries. This brings the oxygen level from venous SpO2 of 70% up to an arterial SpO2 of 100%.
3/
Read 14 tweets
#SurvivingSepsis Campaign Guidelines on
the Management of Critically Ill Adults with #Covid_19

COVID-19 THERAPY

Link: journals.lww.com/ccmjournal/Abs…

#sepsis @CritCareMed @SCCM
#COVID_19 shows Cytokine Storm Syndrome reminiscent of secondary hemophagocytic lymphohistiocytosis

Resp failure in #COVID_19 WO #ARDS - Don't use routine steroids

Resp failure in #COVID_19 with #ARDS- may use steroids shorter course, lower doses

#sepsis @CritCareMed @SCCM
Use empiric abx in hypoxic resp failure + #COVID_19

Identifying bacterial co-infection or superinfection
in pts with #COVID_19 is challenging

Co-infection 5-18% in MERS, Staph aureus common, virulent. Secondary infection 11%, may be Gram-ve organism

#sepsis @CritCareMed @SCCM
Read 4 tweets
1 approach to understanding #covid19 infection is to examine co-morbidities & ask what's common?

Most prevalent Cov19 co-morbs:

1)↗️age
2)Hypertension
3)Diabetes
4)Cardiovascular disease
5)Kidney disease
6)Chronic respiratory disease (esp COPD)
8)Cancers
9)BMI>40
10)♂️>♀️ ImageImageImageImage
2/
These are diverse diseases & increasing age technically not a disease at all. However, there is at least 1 factor in common among all of the co-morbidities identified thus far:

INFLAMMATION
3/
A survey of the co-morbidities revealed another commonality; a close association w/ dysregulation of the pro-inflammatory, neutrophil-recruiting cytokine, IL-17A.

IL-17A is made by multiple immune cell types, including lung-resident innate lymphoid cells (ILC3s).
Read 35 tweets
Starting a series on clinical Pearls I am gathering in #COVID19 patients based on experiences of many experts

Will add as we go along

Feel free to add your own observations/experiences

#covidclinicalpearls /1
Anosmia is likely the most specific #COVID19 related symptom
30% of patients have anosmia as their 1st symptom
#covidclinicalpearls /2
Around 90% of patients have fever.
50% maybe afebrile at the time of presentation
Fever tends to be very resistant to routine measures in hospitalized patients
There is no consensus that NSAIDs are to be avoided in #COVID2019 patients

#covidclinicalpearls /3
Read 66 tweets
(1/) I want to bounce around a disease model for #COVID19. This is hypothesis, some parts are hand-wavy, but I'd like to think a lot is also based on evidence. I'll try to clearly distinguish knowns from assumptions as we go...

#COVID2019 #SARSCoV2 #medtwitter #FOAMcc #FOAMed
(2/)First, whatever #COVID19 is, it doesn't sound like #ARDS. Physiology doesn't line up
1-Easy to vent, but hard to oxygenate. Normal lung compliance
2-Deteriorate rapidly
3-Responds to proning, PEEP, & prolonging I:E
4-Tendency to suddenly de-recruit

atsjournals.org/doi/abs/10.116…
Read 23 tweets
Lessons from past #coronavirus & #influenza #epidemics suggest that #viral #infections can trigger acute coronary syndromes, arrhythmias, exacerbation of heart failure owing to a combination of a significant systemic inflammatory response plus localized vascular inflammation.
#COVID19 may either induce new cardiac pathologies &/or exacerbate underlying cardiovascular diseases. A large proportion of patients have underlying cardiovascular disease &/or cardiac risk factors. Factors associated with mortality include male sex, advanced age, comorbidities.
Acute cardiac injury determined by elevated high-sensitivity #troponin levels is commonly observed in severe #COVID19 cases & strongly associated with mortality. Acute respiratory distress syndrome is also strongly associated with mortality in patients with #SARSCoV2 infection
Read 6 tweets
THREAD: I was sad, but now I am angry. As clinicians, we have the enormous privilege of attending to people when they are at their worst. Death, loss, disease, events that alter the trajectory of people’s lives, and keep working, because there is always work to be done. 1/
We ease the suffering of #humanity. That is what we have been called to do. And I feel like part of that is that we often censor ourselves to protect non-medical people. But how about we start to share a tiny glimpse of our reality? (Medical terminology is in quotes) 2/
While we know that 80% of cases are mild, do you know how people die after being infected with “Severe Acute Respiratory Syndrome #Coronavirus 2” (#SARS_COV_2)?

Rather, do you know how the majority of people who are deceased as a result of the new Coronavirus, perished? 3/
Read 19 tweets
For an entire ER shift, I saw a total of one non #COVID19 patient (TIA, prior strokes, 95yr). Only able to discharge 2 #COVID19 home, rest too sick to convalesce at home. There is a Tsunami coming. The public needs to understand:
- there is no cure,no quick fix, 2 wk of suffering
- sick contact & travel history matters little now
- a LOT of household transmission. This is a BIG problem
- all "flu"s should be treated as #COVID19| isolate, quarantine
- even sick should stay home.Only if short of breath need to be seen.Still may be sent home.
Spread the word
Almost forgot: the data from US could prove very different from Wuhan experience. Young patients become severely ill relatively fast. Multiple patients in their 20-30 in severe #ARDS and two on #ECMO
Read 3 tweets
Corona & Influenza killer viruses & Acute Respiratory Distress Syndrome & treatment
How coronavirus causes fatalities from Acute respiratory distress syndrome (ARDS)
By pulmonologist dr Seheult (medical lectures explained clearly 🤓)
MAP TRACKS CORONAVIRUS OUTBREAK IN NEAR REAL TIME
The Johns Hopkins Center for Systems Science and Engineering has built and is regularly updating an online dashboard for tracking the worldwide spread of the #coronavirus outbreak.
#COVID19 hub.jhu.edu/2020/01/23/cor…
Why have so many coronavirus patients died in Italy?
The country's high death toll is due to an ageing population, overstretched health system and the way fatalities are reported #covid-19

telegraph.co.uk/global-health/…
Read 56 tweets
1/ Please use EXTREME caution with using human resource intensive strategies in patients with #ARDS from #COVID-19.
Very early intubation, very early prone position or early ECMO will expose staff to risk and are unlikiy to bring additional benefit to most patients.
2/ I have been treating and studying ARDS for 20 years and extremely simple approach is by far the most beneficial:
- Try high flow/NIV
- Intubate if above contraindicated/failing (not based on ABGs, no need for ABGs) AFTER informed consent and goals of care discussion
3/ If intubated: AC, low VT (Ppl<30), PEEP 10-15, if needed occasional 10 sec recruitment with PEEP 20-25 going back to 10-15. Occasional bolus vecuronium (+midazolam)for severe asynchrony
- Reverse Trendelenburg in obese
- NorEpi +\- Vaso for MAP 60
- Furosemide, K, Mg
Read 6 tweets
With the #COVID19 outbreak, it is important to use language responsibly. Here is the first entry of our new #ContagiousWords series, defining the buzzwords and terminology dominating today's conversation. #Pandemic #PandemicsCost
@ilariacapua Language is powerful, so we must be sure and accurate in the ways we communicate science. #Epidemic #ContagiousWords #COVID19
Read 64 tweets
NEW: Clinical course and outcomes of critically ill patients with #SARSCoV2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study thelancet.com/lancet/article…
#COVID19 #Coronavirus
Of 710 patients with #SARSCoV2 pneumonia, 52 critically ill adult patients were included. The mean age of the 52 patients was 59·7 (SD 13·3) years, 35 (67%) were men, 21 (40%) had chronic illness, 51 (98%) had fever
32 (61·5%) patients had died at 28 days, and the median duration from admission to the intensive care unit (ICU) to death was 7 (IQR 3–11) days for non-survivors
Read 7 tweets
Draadje over het #coronavirus, wetenschappelijk ook wel het #2019nCoV of #2019_nCov genoemd. Er wordt -en dat is toch wel uitzonderlijk- veel data open access gedeeld.
Het coronavirus is een RNA virus die we in Nederland goed kennen: de meeste verkoudheden worden door dit (en door het rhinovirus) veroorzaakt. Deze virussen zijn niet zo virulent (ziekmakend) en geven neusverkoudheid en bronchitis (luchtwegontsteking).
De laatste twee decennia zien we dat dit virus zich soms muteert en veel virulenter wordt. Bekend is de #SARS-epidemie in 2003 in Azië en de #MERS-epidemie (wereldwijd) in 2014-2016.
Read 25 tweets
Selain berkenaan dengan isu #PolusiJakarta, penyakit paru apa yang perlu Anda ketahui & bisa saya bantu jelaskan?
Weleh cuma bisa 4 ya?
Harap tenang, akan dibahas satu ² sesuai prioritas hasil polling tsb di atas.
Thank you for casting your vote.
Read 19 tweets
A friendly reminder of what an ICU (BSc RGN/ PgD ICU/ PgD CCU) nurse's near top of the scale wages looks like for 2 weeks. And if I work weekends and nights away from my child & partner I might make an extra €100.
#nursesstrike #Nurses @INMO_IRL
My role includes ability to mind complex traumatic brain injuries/ severe sepsis & unstable hemodynamic patients/ continous dialysis/ know how set up & use multiple ventilators & high flow oxygen delivery systems/ assess ABG's & change ventilation settings inc. #ARDS patients/
Respiratory chest physio outside of normal hours/ weekend and night time pharmacy access as no pharmacist during these hours/ ward clerk/ help families & deal with social services/ be a clinical nutritionist & start appropriate feeding outside normal hours as no CN at w/ends/
Read 5 tweets

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