Thread by @NidaQadirMD

#CCCF2020 Brian Kavanaugh Controversies - #COVID19: #ARDS or not? What we really addressed - not so much "is it ARDS?" but rather, "does it matter?" So happy to have been a part of this, but man, I still have so much to say! My take on the ? – yes, it matters - to an extent 🧵 1/

Pre-intubation management: YES, but not because it substantially changes methods of support, or the criteria used for #intubation. It matters because categorizing patients as having #ARDS has value. 2/

If we use the Berlin definition, patients on Venturi masks or arguably #HFNC don’t actually meet criteria for #ARDS because they’re not on PEEP >/= 5. The natural history of ARDS though almost certainly begins prior to the use of mechanical ventilation (invasive or not). 3/

Timing of MV is at least partially dependent on factors beyond the patient (ie, the clinician). Pts who meet all Berlin criteria except the PEEP/MV part also have similar biomarkers of inflammation & injury to those on MV, & more importantly, still have high mortality. 4/

I'm not saying that we should change the Berlin definition – but we should at least recognize that these patients are on the same spectrum as those on MV & be appropriately vigilant about their care & mindful of their vulnerability & severity of illness. 5/

From a research standpoint, this is even more important – such patients aren’t typically enrolled in #clinicaltrials focused specifically on #ARDS. Because of that, there’s not a lot of data about supportive measures for these patients. 6/

With increasing use of HFNC (& a growing body of evidence suggesting its benefit), research targeting this group of patients is needed. Right now, they are incompletely characterized & in a weird grey zone & we may be missing opportunities to help them earlier in their course. 7/

Post-intubation management: YES, this is where it matters the most. Low tidal volume ventilation has been well studied and shown to result in better outcomes, regardless of lung compliance or etiology of #ARDS. 8/

This isn’t just a matter of 6 vs 12 ml/kg PBW – we know from @DrDaleNeedham's work on timing of LTV ventilation that VT increases of as little as 1 ml/kg PBW early in the course of #ARDS are associated w/ mortality. 9/

Re adjunctive therapies – this ? probably doesn’t matter. We do know from pre-COVID cohorts that clinician recognition of ARDS is associated w/ ⬆️ use of adjunctive therapies, which suggests that failure to recognize ARDS may result in a failure to use these therapies. 10/

However, I don’t know that adjunctive therapies are being underutilized in #COVID19 – if anything, there does seem to be increased use of #prone positioning (at least anecdotally) in these patients – although this remains to be quantified. 11/

So ultimately, my take is that “is it #ARDS?” is a question that matters – mainly from the standpoint of understanding & delivering appropriate supportive care. On a less patient-centered level, this debate has also been a really fun and fascinating academic exercise. 12/

Also - none of this is to say that therapies for #COVID specifically don’t exist or shouldn’t be used – we know that treatments such as #steroids & #remdesivir can also be useful. But such treatments should be used in addition to supportive care, not replace it. 13/ (fin)