Professor EM amp PCCSM UWHarborview Tales from Camp COVID No conflicts of interest Salary Support from NIH amp Medic One Foundation Disclosures NickJohnsonMD Tell a Seattle COVID story ID: 934406
Download Presentation The PPT/PDF document "Nick Johnson, MD Assistant" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Nick Johnson, MD
Assistant ProfessorEM & PCCSMUW/Harborview
Tales from Camp COVID
Slide2No conflicts of interest.
Salary Support from NIH & Medic One Foundation.
Disclosures
@
NickJohnsonMD
Slide3Tell a Seattle COVID storyReview evolving approach to COVID ARDSVentilation strategiesNeuromuscular blockade
Prone postureInhaled pulmonary vasodilatorsExtracorporeal life supportFlight considerations
Overview
Slide4January 21, 2020
First Case
Slide5January 21, 2020
First Case
February 26
th
:
“First”
Death
Slide6January 21, 2020
First Case
February 26
th
: First Death
January:
First
Death?
Slide7Slide8Slide9Bhatraju
et al., NEJM 2020
Slide10Initial Presentation
32 year old healthy woman
“Cough”
Temp 38.5⁰C
HR 110
BP 132/82
RR 20
S
P
O
2
66% on air
Slide11here
Your text here
Shunt physiology
Exertional hypoxemia
Unpredictable course
COVID-19 Critical Illness Phases
Acute
Hypoxemia
Distributive shock
Cardiovascular abnormalities
Coagulopathy
Acute kidney injury
Acute hepatitis
ARDS +
Organ Failure
Prolonged critical illness
2ᵒ infections
ICU-acquired complications
Weakness
PTSD?
Prolonged
Illness
Slide12Evolving Approach
Early Intubation & Mechanical Ventilation
(>6L cannula)
Trial of HFNC
Self-
proning
Intubation when needed
Slide13Theoretical Advantages:
Matching of inspiratory flow
Less ambient air entrained
Titrate F
I
O
2
& flow
Humidified
PEEP?
High-Flow Nasal Cannula
Slide14HFNC -
Safety
Miller et al.
JACEP Open
2020.
Slide15HFNC – Efficacy
Demoule
et al.
AJRCCM
2020.
379 patients with COVID-19 acute hypoxemic respiratory failure
Propensity matched: HFNC vs no HFNC
55% [95% CI 46-63]
72% [95% CI 64-79]
Slide16Hours after HFNC
Low risk of IntubationPredicts HFNC Failure
2
ROX > 4.88
ROX < 2.85
6
ROX < 3.47
12
ROX < 3.85
HFNC Success: ROX Index
Roca AJRCCM 2019. Table adapted from David Carlbom.
Slide17Prone?
Huang Lancet 2020
Slide18Awake & Prone
Photo: @
EricLeeMD
Sartini
et al. JAMA 2020
Slide19One Approach
Salim
Rezaie
, www.rebelem.com
Slide20Deterioration
32 year old healthy woman with cough and hypoxemia.
Hospital day #7:
Tachypnea
Somnolence
Worsening hypoxemia
Slide21Airway Management
Timing of intubation
Anticipate desaturation
BVM w/ viral filter + PEEP
Anesthesia bag
CPAP
HFNC
COVID
Slide22Case
Slide23Berlin Definition of ARDS
Acute onset
within 1 week of an apparent
clinical insult
2.
Bilateral opacities
not explained by other pathology
3.
Not fully explained
by heart failure or volume overload
4.
Hypoxemia
: ↓P
a
O2:Fi
O2 ratioMild ARDS: 201 - 300Moderate ARDS: 101 - 200
Severe ARDS: ≤ 100
2012
Slide24COVID-19 & ARDS
Compliance (ml/cmH
2
0)
Shunt Fraction
16 patients
Mean compliance: 50 ml/cmH
2
O
Mean shunt fraction: 0.5 ± 14
Slide25Low compliance?
ARDS Study
Compliance (ml/cmH
2
O)
ACURASYS
(N=162)
32 ± 11
ALVEOLI
(N=273)
31 ± 15
LaSRS
(N=90)
25 ± 12
PROSEVA (N=229)
35 ± 15
COVID ARDS Study
Compliance (ml/cmH
2
O)
Bhatraju
et
al (N=13)
29
(IQR 25-36)
Gattinoni
et al (N=16)
50 ± 14
Ziehr
et al (N=66)
35 (IQR 30-43)
Schenck
et al (N=267)
28 (IQR
23-38)
Auld
et al (N=217)
34 (IQR 28-46)
Slide26COVID ARDS is Heterogeneous
Ziehr
AJRCCM
2020
Slide27COVID-19 & ARDS
Gattinoni
ARDs
Bradley
Lancet
2020
Diffuse alveolar damage
Hyaline membranes
Lymphocytic
alveolitis
Microthrombosis
(5/14)
Rarely: myocarditis (1), pulmonary emboli (2/14)
Slide28ARDS Approach
At-Risk
Mild ARDS
(P:F
201-300)
Moderate ARDS
(P:F
101-200)
Severe ARDS
(P:F
≤ 100)
Consider
Low Tidal
Volume
Ventilation
Low
Tidal Volume Ventilation
V
T
≤ 6 ml/kg PBW,
Plateau ≤ 30 cm H20
P
a
O
2
≥ 55 mmHg or S
a
O
2
≥ 88%, pH >
7.15
Judicious fluids; Address etiology
Address Ventilator
Dyssynchrony
Titrate
PEEP to optimize ∆P, S
P
O
2
,
MAP
Prone Posture
Consider Neuromuscular
Blockade
Consider
ECMO
Consider:
Alternate ventilator modes
Inhaled vasodilators
Recruitment maneuvers
Slide29What does /kg mean?
Mike Meyers is 5’8”
What does cc/kg mean?
Slide courtesy of
Vasisht
Srinivasan
Slide30Treatment: Low Tidal Volume
Plateau ≤ 30 cm H
2
0
Peak
PEEP
ARDSNet
. NEJM 2000.
Time
Pressure
Slide31Treatment: PEEP
ALVEOLI NEJM 2004, LOVS JAMA 2008, EXPRESS JAMA 2008,
Briel
JAMA 2010
↑ PEEP
↑ Oxygenation
↓ Refractory hypoxemia
↑ Compliance
No mortality difference or decrease in ventilator days.
Slide32Treatment: Low Tidal Volume
Plateau ≤ 30 cm H
2
0
Peak
PEEP
Time
Pressure
∆P = Plat-PEEP
∆P =
Plat-PEEP < 15 or best possible
Slide33Treatment: PEEP
PEEP
8
10
12
14
Pplat
24
24
25
30
∆P
16
14
13
16
S
P
O
2
88
89
90
92
MAP
68
68
66
58
Slide34Treatment: Goals
P
a
O
2
≥ 55 mmHg or S
a
O
2
≥ 88%
Plateau ≤ 30 cm H
2
0
pH ≥ 7.15, P
a
CO
2
?
V
T
≤ 6 ml/kg PBW for ARDS
V
T
6-8 ml/kg PBW if at-risk
∆
P
<
15 or best possible
Slide35Potential benefits
Ventilator synchrony
Tolerance of low-tidal volume ventilation
↓ O
2
consumption
↓ Active exhalation
↓ Risk of device dislodgement
Potential risks:
Neuromuscular weakness
Less mobility
More sedation & delirium
Treatment: NMB
Slide36Treatment: NMB
PETAL Network.
NEJM
2019
ROSE Trial
Nonblinded
1006 patients
P:F <150 for < 2 days
48 hours of
cisatracurium
or placebo
No mortality difference
Generally safe
Use NMB if needed for synchrony or refractory hypoxemia.
Slide37Treatment: Prone
Treatment: Prone
Slide38Treatment: Prone
6 trials demonstrating improved oxygenation
No difference in mortality or other patient-centered outcome
PROSEVA, NEJM 2013:
Non-blinded multicenter of RCT
466 patients with severe ARDS
Randomized to early prone vs. supine
Strict protocol: 18 hours prone, then flip
Prone group: ↓ 28-day mortality (16 vs 33%)
Treatment: Prone
Slide39Epoprostenol
& Nitric oxide
Improve oxygenation
No mortality benefit
Treatment: Inhaled Vasodilators
Taylor JAMA 2005,
Walmarath
AJRCC 1996.
Slide40Fluid management
Treatment: Fluid
Conservative Fluid Management
Boyd CCM 2011
Sadaka
J
Int
Care Med 2014
Elofson
J
Crit
Care 2015
Shim J
Crit
Care 2014
Payan
Crit
Care 2008
FACCT NEJM 2006
Slide41Treatment:
ECMO
Severe, refractory hypoxemia or
acidemia
:
P
a
O
2
:F
I
O
2
< 100
pH
< 7.25 with P
a
CO2 > 60
Plateau
pressure >30 mm
HgDespite maximal conventional therapy:Low tidal volume ventilationPEEP optimizationProne positioningConsider neuromuscular blockade or pulmonary vasodilatorsWithout Contraindications:Advanced age Life-limiting comorbidities or immune compromiseProlonged mechanical ventilation
Severe shock or
extrapulmonary
organ failure
Slide42ECMO in COVID-19
1035 patients with COVID-19 who received ECMO
Estimated cumulative 90-day in-hospital mortality: 37%
Barbaro
Lancet
2020
Slide43ARDS Approach
At-Risk
Mild ARDS
(P:F
201-300)
Moderate ARDS
(P:F
101-200)
Severe ARDS
(P:F
≤ 100)
Consider
Low Tidal
Volume
Ventilation
Low
Tidal Volume Ventilation
V
T
≤ 6 ml/kg PBW,
Plateau ≤ 30 cm H20
P
a
O
2
≥ 55 mmHg or S
a
O
2
≥ 88%, pH >
7.15
Judicious fluids; Address etiology
Address Ventilator
Dyssynchrony
Titrate
PEEP to optimize ∆P, S
P
O
2
,
MAP
Prone Posture
Consider Neuromuscular
Blockade
Consider
ECMO
Consider:
Alternate ventilator modes
Inhaled vasodilators
Recruitment maneuvers
Slide44Remdesivir
(ACTT-1) trial
Liberal HCQ
Tocilizumab
widely
March-
April
Pharmacotherapy Evolution
April-
May
HCQ (ORCHID) trial
Little
r
emdesivir
Tocilizumab
selectively
No HCQ
No tocilizumab
Remdesivir
Convalescent plasma
Steroids
June-August
September-
?
Steroids
Remdesivir
?Tocilizumab
?Convalescent plasma
?
mAb
Slide45Treatment: Steroids
Non-COVID
Late steroids → harm
Steinberg
LaSRS
2000
Early steroids → benefit?
Villar
DEXA-ARDS 2020
Dexamethasone vs placebo
Time from dx: 1 day
277 patients, 17 ICUs
4.8 fewer ventilator days
↓
15% absolute mortality
COVID
Steroids → benefit
REACT meta-analysis 2020
1703 patients, 7 trials
Supplemental oxygen, hospitalized
↓ 9% absolute mortality
Slide46COVID ARDS = ARDS. Do the basics well. Adapt to new information, but not too quickly.Ventilate
with low tidal volumes. Check plateau pressure for safety. Titrate PEEP deliberately. Low expectations.Consider ancillary therapies: prone, NMB, inhaled vasodilators, referral for ECMO.Steroids for COVID ARDS, maybe others.
Take Home
Slide47Thank you!
Resources: https://covid-19.uwmedicine.orgNick Johnson, MDnickj45@uw.edu@NickJohnsonMD