Effect of avoiding intubation......

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Marcus Aurelius
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6:21p, 4/19/20
AG
I admit this is total anecdote and small N but I thought I'd share. So I have 3 COVID-19 patients that are gravely ill. ARDS with severe hypoxia. All 3 have required HFNC up to 100% FIO2. A month ago I would have intubated these patients after their oxygen needs progressed beyond 6L NC. Based on the China and Seattle recommendations.

These 3 patients have persevered and are turning the corner. Less FIO2. All inflammatory parameters improving.

I had 3 patients with similar presentation intubated early with high PEEP strategy a month ago. All 3 died.

Is this high level academia evidence research? No. Anecdote city.

But I think there's something to it. I believe the COVID-19 ARDS lung compliance (poor) is such that barotrauma/volutrauma to alveoli is exaggerated for some reasons in these patients. Could it be contributing to cytokine storm?

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jagvocate
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6:34p, 4/19/20
AG
Thank you doc. You're in a battle. Soldiers and Marines share enemy techniques and tactics all the time, that's how we learn and win.

Have you had any patients with normal BMI (Type I Diabetes excepted) suffer a cytokine storm?

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goodAg80
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6:34p, 4/19/20
AG
I read an article that some NYC doctors have stopped intubating and have switched to proning. They are using pregnancy beds to make it even easier to breath. Success rate is high They said.

https://www.nytimes.com/2020/04/14/nyregion/new-york-coronavirus.html

Quote:
Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.

At Lincoln Hospital in the Bronx, Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation; 13 needed ventilators. Proning does not seem to work as well in older patients, a number of doctors said.
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Marcus Aurelius
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In reply to goodAg80 • 6:37p, 4/19/20
AG
Yes. We're proning the crap out of them. But so did my patients who were intubated.
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Marcus Aurelius
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In reply to jagvocate • 6:39p, 4/19/20
AG
jagvocate said:
Thank you doc. You're in a battle. Soldiers and Marines share enemy techniques and tactics all the time, that's how we learn and win.

Have you had any patients with normal BMI (Type I Diabetes excepted) suffer a cytokine storm?
Yes. But my observation is obese patients do much worse with this. I am going to start serotyping anyone who gets admitted as well.
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oragator
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6:52p, 4/19/20
anecdotal but true,
Family member told me a story of someone they knew. Person had Covid, put on a respirator, decided to pull the plug because it appeared hope was lost,, and the person recovered. Which of course is gonna make for an awkward conversation with the family, but I have seen several medical folks lately questioning the value of intubation. Would like to see a real study though.
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Kool
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7:00p, 4/19/20
AG
Awesome stuff!!! What kinds of sats and RRs are you "tolerating " now before intubation?
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Rachel 98
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In reply to Marcus Aurelius • 7:08p, 4/19/20
AG
Really interesting information. Are these the three patients you posted about in another thread that you said were teetering on the edge of cytokine storm and were looking for toci for?
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Necrosis
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7:16p, 4/19/20
AG
How much is obesity contributing? Just curious. Are we talking about BMI > 40 or just run of the mill big as Texas size?

I feel like we have radically moved away from intubating early in favor of HFNC. At least in the early phase of illness this seems to be an oxygenation issue. Thus, increased FIO2 seems to have benefit. If intubating it would make sense you keep these people at low PEEP and escalating FIO2 instead instead. Then climbing in PEEP. Is this what you guys are doing and if so do you see a difference? I've heard that Italy, when intubating, they are needing PEEPs of >14 just to keep up with oxygenation.......

Also, are you anti-coagulating these patients or just ppx?
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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PlanoAg79
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In reply to Marcus Aurelius • 7:33p, 4/19/20
AG
Hey Doc, just read this article about our local hospital using an ECMO machine to save a critically ill COVID-19 patient. Do you have access to one? Article: https://www.nbcdfw.com/news/coronavirus/coronavirus-survivor-on-deaths-door-says-hospital-staff-for-saved-his-life/2353689/
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Marcus Aurelius
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7:39p, 4/19/20
AG
For intubation - obviously PO2 < 55, O2 sats <80% persistent, unstable VS. RR > 40s fatigue, hypercapnea. I omitted the patient who received Toci from these group of 6. Confounding variable. He was intubated and self-extubated. He has been discharged. Unreal turnaround. As far as BMI effect of morbidity. Total anectode but I'd say 35+ plays a role?
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Marcus Aurelius
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In reply to PlanoAg79 • 7:41p, 4/19/20
AG
PlanoAg79 said:
Hey Doc, just read this article about our local hospital using an ECMO machine to save a critically ill COVID-19 patient. Do you have access to one? Article: https://www.nbcdfw.com/news/coronavirus/coronavirus-survivor-on-deaths-door-says-hospital-staff-for-saved-his-life/2353689/
We have 3 ECMO units. Have not used ECMO with COVID-19 yet. As per earlier threads - there are hospitals going to ECMO without a ventilator for advanced respiratory failure in these patients. Incredible high usage of resources and risk / exposure. But interesting. So much data forthcoming.
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cone
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In reply to Marcus Aurelius • 8:00p, 4/19/20
AG
35+?

that's a 8% of men 35-65
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Marcus Aurelius
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In reply to cone • 8:11p, 4/19/20
AG
Yes. Your thoughts?
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Tx-Ag2010
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In reply to Marcus Aurelius • 8:19p, 4/19/20
AG
Marcus Aurelius said:
For intubation - obviously PO2 < 55, O2 sats <80% persistent, unstable VS. RR > 40s fatigue, hypercapnea. I omitted the patient who received Toci from these group of 6. Confounding variable. He was intubated and self-extubated. He has been discharged. Unreal turnaround. As far as BMI effect of morbidity. Total anectode but I'd say 35+ plays a role?


Is it mostly the fat that is the problem or the total weight? I am technically obese given my BMI but am probably only 20-30 pounds away from being where I'd like to with respect to my weight but at 6'4" 265# and fairly muscular, so I dont consider myself obese.
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Marcus Aurelius
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In reply to Tx-Ag2010 • 8:34p, 4/19/20
AG
BMI is what it is. There is no "spinning it." Have had interactions with many patients over the years. "But I'm lean. I don't fit into BMI rules because I'm more muscular." Sorry. The data doesn't support this.
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Tx-Ag2010
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In reply to Marcus Aurelius • 8:41p, 4/19/20
AG
Marcus Aurelius said:
BMI is what it is. There is no "spinning it." Have had interactions with many patients over the years. "But I'm lean. I don't fit into BMI rules because I'm more muscular." Sorry. The data doesn't support this.


Thanks. Appreciate the response.
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gdw4ab
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9:14p, 4/19/20
AG
If I get it, I want to avoid a tube for as long as possible.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Carnwellag2
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In reply to Marcus Aurelius • 9:25p, 4/19/20
Marcus Aurelius said:
I admit this is total anecdote and small N but I thought I'd share. So I have 3 COVID-19 patients that are gravely ill. ARDS with severe hypoxia. All 3 have required HFNC up to 100% FIO2. A month ago I would have intubated these patients after their oxygen needs progressed beyond 6L NC. Based on the China and Seattle recommendations.

These 3 patients have persevered and are turning the corner. Less FIO2. All inflammatory parameters improving.

I had 3 patients with similar presentation intubated early with high PEEP strategy a month ago. All 3 died.

Is this high level academia evidence research? No. Anecdote city.

But I think there's something to it. I believe the COVID-19 ARDS lung compliance (poor) is such that barotrauma/volutrauma to alveoli is exaggerated for some reasons in these patients. Could it be contributing to cytokine storm?

i recognized about 12 of those words
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goodAg80
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In reply to gdw4ab • 9:32p, 4/19/20
AG
gdw4ab said:
If I get it, I want to avoid a tube for as long as possible.
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sincereag
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10:07p, 4/19/20
Gov Cuomo said that 80% of the NY Covid-19 patients who go on an ventilator don't make it. Makes me wonder what impact they are having.
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ham98
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In reply to sincereag • 10:19p, 4/19/20
sincereag said:
Gov Cuomo said that 80% of the NY Covid-19 patients who go on an incubator don't make it. Makes me wonder what impact they are having.
I think people would be really angry at being put in an incubator
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Not a Bot
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10:30p, 4/19/20
AG
Our hospitals here have not invested in high-flow nasal cannula machines. Once you're past 6 liters you're on a mask or in many cases, intubated.
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ham98
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In reply to Not a Bot • 10:32p, 4/19/20
Moxley said:
Our hospitals here have not invested in high-flow nasal cannula machines. Once you're past 6 liters you're on a mask or in many cases, intubated.
Can your procurement dept ask the feds for an assist?
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cone
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In reply to Marcus Aurelius • 10:36p, 4/19/20
AG
my thoughts? that's not good.
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jakeaggie84
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12:07a, 4/20/20
AG
So we had TOO MANY ventilators all along and they were making people worse!? What a plot twist that would be!

Very interesting following all the first hand anecdotes.
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dgb99
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11:37a, 4/20/20
AG
Very interested in any more discussion on this. My 75 yo dad has been in and out of the hospital since at least early February dealing with a laundry list of issues that are all the things you don't want to have if you end up getting COVID19 (heart disease, COPD, lung cancer).

He tested positive last week and is currently using a non-rebreather mask (I am obviously not a doctor and had to google image search what that was) using 15L/min of O2 per my brother's conversation with his nurse. If he takes the mask off for more than a few minutes his O2 sat goes down fast (97 while wearing the mask). The nurse indicates 15L/min is very high usage of oxygen.

Today, they are trying to drop to 10L/min to see what happens (with hopes of sending him home if they can get him down to 5L/min with a normal cannula). If he doesn't do well, our understanding is the options are to put him back on 15L, sedate and put on a vent, or try 'high flow oxygen' which the nurse said is less common.

I don't know what the difference or benefit might be between the 15L/min on non-rebreather mask vs. the 'high flow oxygen' which I'm thinking might be the high-flow nasal cannula machine mentioned here.

The situation sucks regardless but is compounded by the fact that he is in a hospital in relatively small town Georgia, I'm in Plano, my brother and sister are in the Chicago burbs, and none of us can go visit him and/or talk directly with the doctors.
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Marcus Aurelius
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In reply to dgb99 • 11:49a, 4/20/20
AG
High flow nasal cannula HFNC. Awesome O2 delivery system. It has been compared with research trials to BIPAP for non-hypercapneic hypoxic respiratory failure. Superior. Nice because you can dial the exact FIO2 you want up to 100%. They make automatic titraters that vary the FIO2 based on patient pulse oximetry data fed inline to the HFNC system. You set minimum O2 sat allowed - i.e. 90% etc.
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dgb99
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12:28p, 4/20/20
AG
Thanks! And thanks in general for your posts with your experiences on this board...I've found them helpful/interesting while still setting the right tone for what could/should be done with the information.

The following link seems to expand on some of the benefits of HFNC over the non-rebreather mask my dad is currently using. I will try to confirm if this is an option at the hospital he is at.

https://rebelem.com/high-flow-nasal-cannula-hfnc-part-1-how-it-works/



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TRADUCTOR
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In reply to Marcus Aurelius • 12:32p, 4/20/20
Marcus Aurelius said:
exaggerated for some reasons in these patients. Could it be contributing to cytokine storm?
I say fear
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TRADUCTOR
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In reply to gdw4ab • 12:34p, 4/20/20
gdw4ab said:
If I get it, I want to avoid a tube for as long as possible.
Good to know, Thanks.
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Gizzards
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In reply to Marcus Aurelius • 1:59p, 4/20/20
AG
This may be anecdotal but has been written about by several groups in the past two to three weeks. A group from Germany published an article outlining the perceived damage caused by intubation and increased PEEP. It was met with several comments here that all ARDS is treated the same way. Our intensivists started this two weeks ago and have seen significantly improved outcomes in hypoxemic patients. I'm glad that you are seeing the improvement that we are.
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riley290
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5:43p, 4/20/20
AG
I'll do anything I can to not intubate. My nurses at NY Metropolitan at this point will tolerate me leaving patients on the floor proned usually on both HFNC and oxymask since they mouth breath so much (though today we were down to three masks left) satting in the mid to high 80's at total rest. Once they move they'll hit the 60-70's for a few minutes until they get told to prone and stay still. Really doing anything I can to avoid positive pressure ventilation, I have had a few guys ride like this for 3-4 days and then quickly improve within 1-2 days to nasal cannula and sitting upright eating.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Marcus Aurelius
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In reply to riley290 • 5:45p, 4/20/20
AG
Thx yes. Agree. I'm certain this is the way to manage these pts. Which makes me wonder. Why the "intubate early" recommendations from China and Seattle? Please chime in on this board more. Sounds like you are in the "thick of it."
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Marcus Aurelius
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In reply to Not a Bot • 5:53p, 4/20/20
AG
Moxley said:
Our hospitals here have not invested in high-flow nasal cannula machines. Once you're past 6 liters you're on a mask or in many cases, intubated.
Man. That is not good. You need to remedy that. They have become my favorite O2 delivery method in hypoxic respiratory failure. Which is nice in COVID-19 patients as I have not seen a lot of hypercapnea. Which tells me COVID-19 is more R>L shunt physiology rather than V/Q mismatch. Perfect for HFNC.
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