This page is for discussion among EM residents, faculty, staff.
Do not post anything inappropriate. It should only be for serious discussion.
Room9er ["Room Niner"]:
The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine
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TLDR- are we still gonna avoid NIV for suspected covid and go straight from relatively low fio2 –> tube? See links at the bottom.
I know early on we (and everybody else) had been planning to avoid NIV and HFNC for fear of aerosolisation and concerns regarding likely failure. I was all about this cos I don’t wanna get covid.
Initially there was a lot of talk about how this was classic ARDS that needed high PEEPS (or APRV) and oxygen alone wasn’t going to cut it.
I’m reading more and more foamed sources from NYC/NJ saying that this isn’t classic ARDS and these patients have completely normal compliance but very low o2 SATs. People comparing it more to HAPE (very low SATs in patients who look comfortable), pulmonary hypertension (very high mortality, >50%, in mechanically ventilated patients) or even a hemoglobinopathy given the clinical picture doesn’t really fit the SATs (people sitting up texting with sats in 50s).
There seems to be a lot of positive talk about the New Orleans data but seems to me that so far even they’ve only been able to extubate 40-50%. Though I guess that number could change as many are still alive and intubated. I imagine Dr Baker might know how things are looking there.
Just wondered if we were planning on sticking to a no NIV/HFNC plan or not? If not do we have NIV machines with dual circuits or would we have to use vents in NIV mode/some of the Jerry rigged stuff people are trying in NYC/California? Seems to me closed circuit CPAP/PEEP may be the best combination of high fio2, little bit of positive pressure and hopefully low aerosolisation.
I included a couple sources below which are interesting. One is a Salim Rezaie article summarising his thoughts on aerosolisation based on some exhaled smoke dispersion stuff. The other is a more concerning article from Nebraska basically saying they found COVID on everyone and everything including the air even when patients were wearing only regular low flow nasal cannula (though to be fair they weren’t sure if the viral particles found in the air were enough to spread infection)
Foam stop intubating advice-
https://emcrit.org/emcrit/stop-kneejerk-intubation/
https://thinkingcriticalcare.com/fbclid=IwAR364j6uuFRdAzIJL_1KvUXvm2h3PFbdyeeUlHFYsJgxlc2hEodY_dS-de8
https://youtu.be/GLbKyc31XhM (EMRAP LIVE- all interesting but skip to Swaminathan for their experience with early tubes)
Rebel em article re aerosolisation –
https://rebelem.com/covid-19-hypoxemia-a-better-and-still-safe-way/?utm_source=rss&utm_medium=rss&utm_campaign=covid-19-hypoxemia-a-better-and-still-safe-way
Nebraska study re aerosolisation-
https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2
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