Viren Kaul, MD Profile picture
Oct 17, 2021 16 tweets 16 min read Read on X
Live at 1400 ET: chestmeeting2021.junolive.co/live/mainstage…

"Airway management in the era of severe pneumonia" with #CHESTairways experts from the Airway Domain Task Force.

Will live tweet this talk on this #CHEST2021 thread.

Speakers:
@Chaeface @KDoerschug @J_Mendelson_MD and yours truly! Image
Let's get started with WHY our session is important:
🔥 Appx. 10% emergent intubations may result in failed airway
🔥 It's not just anatomical challenges, but physiological ones that have to be considered, esp with severe pneumonia
🔥 Lessons from the pandemic

#CHEST2021
* Let's talk about the vicious cycle of injury that occurs in acute resp failure (pic 1)
* Clinical course of disease imp for decision to intubate (pic 2)
* Ideal timing related to worsening work of breathing (pic 3)

PMID: 32747391
PMID: 27626833

#CHEST2021 #CHESTairways ImageImageImage
Prediction scores:
* Pic 1: Cabrini Strain Scale: PMID: 32521584
* Pic 2: ROX Index: PMID: 30576221
* Pic 3: HACOR Score: PMID: 31565779

ROX & HACOR may correlate w/ failure or success of therapy in resp failure

#CHEST2021 #CHESTairways ImageImageImage
How can we clinically assess the work of breathing?

Tulaimat (PMID: 27288621) studied this: Check out the sensitivity and specificity of exam findings. More signs of inc WOB, more sens/spec the decision usually

Pic 2: From Apigo et al (PMID:  32736637)

#CHEST2021 #CHESTairways ImageImage
Now we have thought about WHEN we need to intubate, let's look at the other side: How long can we safely tolerate apnea?

This classic graph from Benumof (PMID: 9357902) from 1997 says it all!

Worsening illness and higher weight narrows the apnea time #CHEST2021 #CHESTairways Image
Ergo, with increasing risk of desaturation, the pre and intraprocedural interventions should get more appropriately aggressive as Moser describes

#CHEST2021 #CHESTairways Image
Let's talk pre-oxygenation:
PaO2 only increases a little bit with #PreOx in critically ill patients --> reflects the marginal reserve these patients have, as we have all seen with #COVID19Vic

Pic PMID: 16276196

#CHEST2021 #CHESTairways Image
As Casey showed in 2019: BVM improves the degree of hypoxemia during #ApneicOxygenation vs. no ventilation. This is a CORE skill for airway operators!

PMID: 30779528

#CHEST2021 #CHESTairways Image
Patient positioning matters:
Sniffing pos: Aligns airways
Ramped pos: Helpful in low FRC conditions (obesity, ascites, pregnancy)

Data is split, see pic here.
Optimize to the patient!

PMID: 28487139
PMID: 26866753
PMID: 31895986

#CHEST2021 #CHESTairways Image
Let's talk holding technique for BVM ventilation.

This 2017 study showed better ventilation (Vt) with V-E technique vs. C-E technique (PMID:  28403406)

To reiterate, positioning, BVM technique, #ApOx and #PreOx are all important considerations.

#CHEST2021 #CHESTairways Image
Ah! Now the classic debate: To use paralytics or not?

In this observational trial of 566 emergent intubations (>200 by trainees), use of NMBs:
* Fewer attempts
* Better views
* Fever complications

PMID: 22610185

#CHEST2021 #CHESTairways Image
What causes failed airways and leads to issues with management?

* Not being recognized
* Unstructured approach
* Training and preparation
* Inadequate support/equipment

Amongst other reasons, as described by Cook and team (NAP4 study, PMID: 21447488 )

#CHEST2021 #CHESTairways ImageImage
Having a solid APPROACH to ICU intubations is key for preventing adverse outcomes

Here is the APPROACH strategy advised by @accpchest airway course universal ICU intubation management algorithm

#CHEST2021 #CHESTairways Image
🛑Know the failed attempt criteria
🛑 Failed airway? -> CALL FOR HELP!!!
🛑Follow a pathway that you as well as your team knows well and have prepared/practiced for
🛑 Here's the non-emergent @accpchest pathway

#CHEST2021 #CHESTairways Image
There are other algorithms/pathways such as @dasairway pathways and @VortexApproach

🔑 points:
🔺Prepare, prepare, prepare
🔺Systematic APPROACH
🔺Recognize failed airway ASAP
🔺Ask for help early
🔺Follow practiced interdisciplinary pathway

#TeamApproach
#CHEST2021

fin/

• • •

Missing some Tweet in this thread? You can try to force a refresh
 

Keep Current with Viren Kaul, MD

Viren Kaul, MD Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!

PDF

Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @virenkaul

Oct 20, 2021
Next up for me: Changing Landscape of Prone Positioning with @sqsimp @GallodeMoraesMD @md_ritwick and Dr. Bosch.

Follow this thread 🧵 for pearls from this session.

#CHEST2021 #CHESTtrainees
Abbreviations:
PP = Prone Positioning
APP = Awake Prone Positioning
ARDS = You know it!
ARF = Acute Resp Failre

So then, let's learn!

#CHEST2021
Dr. Bosch:
What is APP? Proning patients who are not mechanically ventilated (MV)

He's presenting a case, let me ask you in the meanwhile; Do you perform Awake Proning?
Read 20 tweets
Oct 20, 2021
Attending "Approach to Management of Pulmonary Infections in Immunocompromised Patients", LIVE right now on the #CHEST2021 platform, a thread🧵
. @kriscrothers: Diagnostic evaluation in patients with HIV include (pic 1)
* Historical elements
* CD4 count
* Chest imaging pattern

Know you infectious and non-infectious processes that can happen with decreasing CD4 counts (see pic 2)

#CHEST2021
.@kriscrothers: Compares bacterial pneumonia vs. PCP vs. TB
* > 1 infectious process in 10-20% pts with HIV
* Targeted Rx is key

W/U:
* Expectorated/induced sputum
* Sputum AFB x 3 w/ NAAT in 1 sample
* Bronch: If sputum negative for TB or no sputum for PCP

#CHEST2021
Read 13 tweets
Oct 18, 2021
Live-tweeting #PardonTheInterruption with @davidschulman

1. Will Bender
2. Bennett Deboisblanc
3. Ronald Goldenberg

Some punches are being thrown already ..

Somehow we brought up national chocolate cupcake day, whut? :-p

#CHEST2021
Topic: Role of Remdesivir for COVID-19:
WB: No data to support, even @WHO doesn't support it.
BD: Cost for quality low. Mortality benefit from best MA shows mortality benefit.
RG: No way, we don't do that up north! Maybe there is dec LOS, hell no on mortality.
#CHEST2021
What if pt already on Remdesivir prior to coming to ICU:
WB & RG: We continue
BD: Why, why, why? You don't want to start it, but want to hold on to it?
#CHEST2021
Read 9 tweets
Oct 17, 2021
There's a lot to take in on the #CHEST2021 platform, but don't forget to check out the e-posters. I want to highlight a few that caught my attention!

Pic 1: Aerobic exercise improves #Asthma phenotype in severe asthma
Pic2: Positive correlation b/w ONSD and ICH volume #POCUS1st ImageImage
Silvestri & co:
** Remimazolam safe & effective to achieve moderate sedation for flex bronch
** Faster sedation onset & recovery vs. placebo w/ rescue vs. open-label midazolam
** Ready for discharge sooner

#CHESTIP #Bronchoscopy #CHEST2021 Image
.@sarangspatil1: Preop HFNC in patients undergoing cardiac surgery associated with reduction in postop pulmonary complications & risk of post-op infections.

Scan the QR code for more details.

#CHEST2021 Image
Read 5 tweets
Oct 17, 2021
Done with the talks for today at #CHEST2021 .. Now to the opening session. So nice to see leaders sharing gratitude and giving thanks. It’s the small things that matter! @CHESTPrez Image
.@CHESTPrez acknowledges massive amount of work performed diligently by the #COVID19 task force and the @accpchest staff who led this virtual pivot with aplomb.
#on a personal note I’m so proud of my friends @GallodeMoraesMD @drdangayach for the presidential citation

#CHEST2021
.@CHESTFoundation award winners honored and now @davidschulman has taken on the mantle of @CHESTPrez!!

#CHEST2021 Image
Read 6 tweets
Apr 2, 2020
Spoke to three close friends today. Just checking in on them since they are working at hotspots.

Here are direct quotes from those very people working >16 hours a day battling #COVID19

“I am suffering panic attacks.”

Think about that
Let me share with you why
“Coworkers are falling sick left & right. Every night as I lie in bed away from my fiancé, I think about falling sick, getting intubated & dying”

“What will my parents do”

“I can’t get over the fear in my fathers voice. I tell him I have #PPE, fact is he knows, and I know too.”
“People keep saying we are the brave front line workers. We see videos of cheering from balconies. But deafening silence as we wait for testing to return 3 days later on our sick patient.

We ask, and the answer is the same, it’s ramping up. So is our risk. #COVID19
Read 11 tweets

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Follow Us!

:(