Thread by @MRamzyDO

From experience in our #COVID19 ICU so far:

What started as an HFNC ICU has quickly turned into an ARDS unit treating iatrogenic ALI from patients being intubated

#COVIDfoam #FOAMed #FOAMcc @cameronks @PulmCrit @ThinkingCC @srrezaie @First10EM @gattinon @precordialthump

1/12

As physicians we see a low SpO2 combined with a low PaO2 & the knee jerk reaction is early intubation instead of assessing patient's overall clinical picture including their work of breathing & mental status. Here's a walk through what happens after...

2/12 #COVIDfoam #Covid_19

Following intubation, patients are put on higher PEEPs which combined w/ACE-receptor effects of virus worsens their already slightly elevated creatinine. Higher PEEPs causing increased thoracic pressure understandably leads to hypotension so patients are then given fluids

3/12

That fluid accumulates on top of the inflammation already in their lungs giving off the picture that they are getting worse (again from what we assume as the natural course/progression of #COVID19)

4/12

As their SpO2 drops from all our interventions…. our natural inclination is to turn up the PEEP even more as they have been on high FiO2 this entire time, what other choice is there at this point

5/12 #COVIDfoam #Covid_19 #FOAMed #FOAMcc

Barotrauma leading to a pneumothoraces gets these patients chest tubes, Rising creatinines get them trialysis catheters to prepare for dialysis/CVVHD, worsening hypotension gets them on pressors. They eventually succumb to all of this...

6/12 #COVIDfoam #Covid_19

We only bring in one family member at a time to say goodbye.

Its at this point, many ask, should we be trying something new? How'd this happen to such a young person? We need to recognize that #COVID19 is unlike any disease we’ve seen. We need to go back to the beginning

7/12

First stop intubating early & consider the following (assuming full PPE)
- Assess patient’s mental status & overall WOB…Like SpO2, Respiratory Rate may not be as reliable as they seem more comfortable intentionally take faster more shallow breaths.

8/12 #COVIDfoam #Covid_19

- Graduate O2 requirements to HFNC (having them close their mouth gives a tiny amount of PEEP which may be thats needed)
- Awake Proning aka “Pig-Roast” = patient changes positions every hour
- DONT RUN MAINTANENCE FLUIDS
- Pulmonary Vasodilators Utility... tbd

9/12 #COVIDfoam

Rising pCO2, changes in mental status & worsening clinical picture may be trigger for intubation, but avoid it if possible

-Once intubated, use apneic CPAP (see @emcrit), the lowest PEEP settings possible, high FiO2 & avoid ARDSnet.

10/12 #COVIDfoam #Covid_19 #FOAMed #FOAMcc

Please do not misinterpret this as saying there is absolutely no ARDS component. Infact, these patients may still progress to ARDS, in which case treat them appropriately. However this is more of an oxygenation then ventilation issue and higher pressures will not help

11/12

We are still learning more about #COVID-19 but as we do so, need to acknowledge that this IS different from anything we have seen before.

Treating this new disease with old treatments will mean old results & more people will dying unnecessarily…

12/12 #COVIDfoam #Covid_19