Thread by @PulmCrit

#1/ with an exponential rise in COVID cases, it's time to talk about how to avoid running out of ventilators. NYC is encountering this now, and other locales will follow shortly. ICU resources (especially invasive ventilation) are unfortunately finite...

#2/ sharing ventilators, using oxylators, or adapting BiPAP devices may be good options (more here: bit.ly/2wGiT5l). however, these don't fully solve *related* problems (e.g. number of respiratory therapists, exhaustion of sedative & paralytic supplies, ICU beds)...

#3/ the best option is avoidance of intubation entirely. this report suggested that HFNC or noninvasive ventilation (+/- awake pronation) could dramatically reduce the rate of intubation (and perhaps mortality as well).

#4/ awake proning isn't for everyone (requires a cooperative patient). not much data, but proning is felt to work among intubated COVID pts. non-intubated COVID patients have the *same* physiology. so maybe worth a try (it's free!).
(IBCC section: bit.ly/2UkiMpa)

#5/ CPAP doesn't yet have a good evidence basis in COVID. however, my guess is that this may be the most effective noninvasive technique. early application could be more effective (*maintaining* an open lung is easier than *recruiting* collapsed tissue)
emcrit.org/pulmcrit/cpap-…

#6/ the single best option could be CPAP via a helmet interface (which appears to be used to good effect in Italy). if there are any engineers out there looking to save the world, please 3D-print us some CPAP helmets.

#7/ application of CPAP and HFNC has been hampered by fear of virus aerosolization. these concerns largely represent fear-based medicine, rather than evidence-based medicine. a patient coughing into a mask with a viral filter is probably better than coughing right in your face?

#8/ updated approach to respiratory support incorporating awake proning. perhaps this is a wee bit desperate, but these aren't exactly normal times. as we run out of vents, the noninvasive strategies will become increasingly appealing 😬
(more in IBCC: bit.ly/2QR57nA)