Thread by @ogi_gajic

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

4/ - Steroids for usual indications (COPD, septic shock) or rapid worsening/cytokine storm (CRP>100)
- Extubation as soon as possible to NIV/high flow
- Don’t use inhaled vasodilators, esophageal balloon, nebulizers, bronchoscopy or any experminatal therapy outside research

5/ - I have not needed to prone a patient since 1999 but I could imagine trying in hemodynamically stable refractory hypoxemia (sustained SpO2 <90 on FiO2 100%).
- I have never sent a patient for VV ECMO. (VA ECMO for temporary pump failure is different story)

6/ With this approach I have had fantastic results with both good life (return to baseline health) and good death for my patients.
This approach will also maximally protect both your staff & your patients by minimizing non-essential noise, iatrogenesis, &?experimenting.
The End