Dr. Gattinoni or: How I Learned to Stop Worrying about P-SILI and Love Furosemide
WEIRD THREAD 🧵 About the blood-gas barrier and #COVID19 (1/9)
WEIRD THREAD 🧵 About the blood-gas barrier and #COVID19 (1/9)
Clinical Case: A 4 year old Thoroughbred Horse with a history of recurrent racing-associated epistaxis comes to your office complaining of decreased track performance. He wants to know if there is anyway to prevent this from happening (2/9)
What treatment would you recommend? (3/9)
Exercise-induced pulmonary hemorrhage (EIPH) results from disruption of the pulmonary capillaries 2/2 ⬆️ Longitudinal tension (lung inflation) and ⬆️Trans-Capillary Pressure (⬆️LVEDP + Negative pleural pressure) during exercise at max aerobic capacity in 🐎. PMID: 17021008 (4/9)
Interestingly, randomised control trials show that prophylactic administration of IV furosemide (500 mg) decreases the incidence and severity of EIPH. #DiuresisJedi
** Obviously this is treating the hydrostatic pressure component of trans-capillary pressure (5/9)
** Obviously this is treating the hydrostatic pressure component of trans-capillary pressure (5/9)
Capillary disruption (although less severe) also occurs in humans. IronMan athletes get reversible pulmonary edema after a race. NPPE develops in pts w upper airway obstruction. Pulmonary edema has been reported in DKA w high tidal volume. (6/9)
This has lead several authors to speculate that patients with ARDS and increased respiratory drive can self-inflict lung injury (P-SILI) through increased tidal volumes and increased trans-pulmonary pressure. Early intubation and IMV are thought to mitigate P-SILI. (7/9)
What is the actual evidence that early intubation prevents P-SILI? Actually there is only one study: 🐑 sheep injected with sodium salicylate to the brain (which ⬆️ respiratory drive) develop alveolar injury. IMV + sedation prevented this. THAT'S IT (8/9)
Highly negative pleural pressures can lead to lung edema through ⬆️trans-capillary pressures. It is plausible that P-SILI plays a role in ARDS progression. As for evidence that early intubation + IMV leads to better outcomes in humans? I'd say hold your horses (9/9)
This awesome physiology is further explained in depth by my eloquent friend Aman here 👇
