Thread by @AmitGoyalMD

1/ ❤️🤓 Time to reacquant yourselves for ARDS management!

Here is a @cardionerds #tweetorial review of this phenomenal lecture:

🔥On ARDS in #COVID19 🔥

By @AnnGageMD, @RanLeeMD & @AndrewHigginsMD

Video:

Article: casereports.onlinejacc.org/content/early/…

2/ I need a PA Catheter to diagnose ARDS to rule out cardiogenic pulmonary edema:

3/ 🤔Why pay attention?

We can't afford not to! 👩‍⚕️👨‍⚕️

🤒ARDS is a MAJOR part of COVID19 illness:

⛔️Wuhan: 6% needed vents, 3.4% get ARDS
⛔️Italy: 10% got ARDS

💥US: plan to manage ARDS regardless of specialty 😥

But Don't worry: we got you #InThisTogether

4/ ARDS…what's that???😱

Acute lung injury from direct insult or systemic process...ouch!

✅Berlin Definition
1. Acute

2. Bilateral

3. Noncardiogenic (clinical determination)

4. PaO2:FiO2 = P:F (with PEEP at least 5cmH2O):
MILD < 300
MOD 200-300
SEV < 100

5/ ARDS in the COVID-era: General Tenets

☑️Rapid progression
☑️⬆️Aerosolization w HFNC or NIPPV
☑️Early Intubation
☑️Avoid:
-- HFNC > 30 LPM
-- NIPPV with VT > 9.5cc/kg

6/ Ok ok...enough background.

Let's meet our patient 🤒:

SC is a 29 yo F nurse w/ #COVID19 p/w Hypoxia 👩‍⚕️

Questions:

1⃣How to oxygenate?🤔
2⃣When to intubate?⌛️
3⃣How to safely intubate?😷
4⃣Lung-protective ventilation -- huh?😲
5⃣Ventilation goals🏁

7/
1⃣How to oxygenate?🤔
-- Can try NC for SpO2 92-96 with < 6LPM
-- Consider HFNC or NIPPV per🏥policy
-- BUT early intubation

2⃣When to intubate?⌛️
> 6L NC w/ SpO2 < 92%
> 30LPM HFNC (virus --> air)
> 9.5cc/kg NIPPV (lung injury!)
> Rapidly worsening

8/
3⃣How to safely intubate?😷

👩‍⚕️PROTECT HCWs👨‍⚕️

⬇️MINIMIZE EXPOSURE⬇️

✅Proper PPE
✅Minimize bagging --> NRB
✅Minimize attempts:

☑️Most experienced provider
☑️Video Laryngoscopy

9/
4⃣Lung-protective ventilation -- huh?😲

Goal tidal volume is:

10/
4⃣Lung-protective ventilation -- huh?😲

Ventilator: HURTS the lungs! - Ouch! 😫
🚫Volutrauma
🚫Barotrauma
🚫Oxygen Toxicity

ARDSnet: Lung-Protective Mechanical Ventilation to PROTECT the LUNGS!

11/
Pillars of Lung Protective Ventilation

💥Low TV: 6cc/Kg of IDEAL Body Weight

...wait, but wouldn't this ⬇️min ventilation & ⬆️CO2⁉️

YES, but that is ok (up to a point)👌

💥Permissive Hypercapnea
💥Relative Hypoxemia
💥Low Plateau Pressure

12/ ok we got this! Protect the lungs...but what mode do I ask my RT to start with? 🤔

Let's cover Vent Modes! 👏

💥Assist Control (AC)

Vs

💥Synch Intermit Mandatory Vent (SIMV)

…ringing any bells? 🔔 Ya...me neither; Let's revie together!...

13/
💥Assist Control

You set a pre-specified deliver of:

A) Pressure (Pressure Control)
-OR-
B) Volume (Volume Control)

The same P or V support is delivered with EACH breath, for BOTH:

a) Set RR triggered by vent
b) Extra breaths triggered by pt

14/
💥SIMV

Same as AC but with 1 MAJOR difference:

You still set a Pressure OR Volume

And the RR

BUT the patient-triggered breaths get less or no extra support

15/ Great, you mastered common vent modes. Now let's return to SC, our patient with ARDS...so many options; what do we tell our RT⁉️

For ARDS, want to minimize lung injury.

Tightly control the tidal volume

So start with VC/AC = Volume Control / Assist Control

16/Gotcha, start AC/VC in ARDS...but HOW?

It's easy, just...

✅Set 4 parameters:
▶️TV & RR (manage CO2)
▶️FiO2 & PEEP (manage O2)

Let's go through each!

17/
▶️Tidal Volume (TV)

Start with 6cc/kg of

IDEAL Body Weight

Based on HEIGHT

So PLEASE measure the HEIGHT properly!

18/
▶️Respiratory Rate

🦪Pearl: match their pre-intubation minute ventilation

Start 14-20 bpm, but may up due to low TV

19/
▶️FiO2: go big or go home (but not too big),,,Start at 100% and titrate down!

▶️PEEP ~8cmH2O for most, but with caveats!

20/
🛣️Are we there yet? ALMOST! 🏁

Take a quick coffee break☕️

21/ We're back!
You've intubated SC and set initial AC/VC parameters.

The first (30min) ABG is cooking 🍳

💥Things change rapidly💥

After initial settings:
1) Reassess
2) Titrate

22/
5⃣Ventilation goals🏁

GOALS:

✅Permissive Hypercapt: pH > 7.25

✅Relative hypoxemia: PaO2 55-80mmHg, SpO2 92-96%

✅Low Plateau Pressure < 30cmH20

23/ Things are dynamic in the ICU‼️

💥Ventilator Titration💥

☑️⬇️ RR for pH ~7.25
☑️⬇️FiO2 for SpO2 92-96% & PaO2 62-80
☑️Adjust TV & PEEP for Pplat goal < 30

See the low PEEP table

24/ I'm doing it all right, but it's not enough!

💥Bail-out strategies💥
✅High PEEP strategies
✅Neuromusc blockade
✅Prone Position ventilation
✅VV-ECMO (or VA-ECMO w/ concurrent 💔)

Excelleng Pront Positioning Tweetorial by @BBroderickMD:

https://twitter.com/BBroderickMD/status/1244489247987564554

25/ NOW we're there!

Wow this was helpful and I can't wait to watch this lecture:



By @AnnGageMD @RanLeeMD @AndrewHigginsMD

Video production by beloved #CardioNerds @Dr_DanMD

...now only if I can learn how to spell "reacquaint"! 🤣

For those of you who "DISAGREED": thank you! Would love your feedback for this (my 1st tweetorial). Please reply or DM me. 🙏

...and YES; CardioNerds share awesome lectures on our YouTube channel.

1. Subscribe & Enjoy: youtube.com/channel/UC0EZv…

2. Let us know if you see, hear, or present one that needs to be shared with our audience‼

@Dr_DanMD @RichaGuptaMD @rsloungani @nauffal_victor @DeepakAtriMD

Correction:

This should be PREDICTED body weight!