Corticosteroids for COVID-19

Some legendary names came out to play for this article. Meduri is the author of the famous Meduri Protocol for methylprednisolone in ARDS and Villar is the author of the article I shared on February 13th (seems like forever ago, really) where they provided dexamethasone for ARDS and showed a mortality benefit amongst many others. I personally like looking into strategies such as corticosteroids as they are inexpensive and available worldwide. You can't really count on third world countries obtaining a -zumab drug. This paper is an opinion piece and is missing formal RCT data. I recommend you read the article yourself and don't trust me. This is not medical advice but I am carefully administering corticosteroids to my COVID patients based on certain clinical and laboratory criteria. It is a custom tailored approach so I can't say exactly what I'm doing. Every patients is different. I am trying to reach for dexamethasone to avoid my team having to go into the room numerous times a day to give a medication. 

Steroids for Cytokine Storm
The authors state that the cytokine storm is what kills COVID patients. I do not disagree with this. You watch the ferritin and CRP spike up and the patient get sicker (we don't have IL-6 at our shop). Their O2 requirement goes up, their renal function starts to worsen. Things get ugly and in a hurry. Some use the -zumab drugs which we have all have a certain allocation of and is expensive, but what if we can reach for plentiful and cheap steroids instead? We all know the adverse reactions to this. The authors cite how the WHO guidelines on steroids is misleading and potentially harmful. 

The Evidence for Steroids in ARDS
We do not have great studies in all this. We have harped on this enough. The authors acknowledge this and pull observational data from Wuhan where there was a decreased risk of death for giving methylprednisolone to the patients in ARDS. They acknowledge that randomized controlled trials are ongoing but that we should not withhold giving patients steroids in the ICU for ARDS in lieu of study results. I know I'm not allowing my patients to wait themselves. 

Simple yes or no question to you all: Are your teams providing steroids to your COVID patients?

-EJ

Villar, Jesús MD, PhD; Confalonieri, Marco MD; Pastores, Stephen M. MD, MACP, FCCP, FCCM; Meduri, G. Umberto MD. Rationale for Prolonged Corticosteroid Treatment in the Acute Respiratory Distress Syndrome Caused by Coronavirus Disease 2019, Critical Care Explorations: April 2020 - Volume 2 - Issue 4 - p e0111 doi: 10.1097/CCE.0000000000000111

Link to Article



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Respiratory Management Protocol of Patients with SARS-CoV-2

First of all, a big hat tip to the authors:

Aurio Fajardo C; MD. Medicina Interna. Unidad de Paciente Crítico. MsC en Ventilación Mecánica, Universitat de València. MsC en Medicina Intensiva. Grupo Ventilación Mecánica Chile - Drive Flow Org. Viña del Mar. Chile. @drive_flow_org

Alberto Medina V; PhD. MD. UCIP. Hospital Universitario Central de Asturias. Oviedo. España @alberto_medina_villanueva

Angelo Roncalli; PT. MsC. Hospital Escola Helvio Auto Maceió. Brasil @angelo.roncalli

Enrique Monares Zepeda; Médico Intensivista. Ciudad de México. @enriquemonareszepeda

Federico Gordo-Vidal; MD. Hospital Universitario del Henares. Coslada- Madrid. Grupo de Investigación en Patología Crítica. Francisco de Vitoria, Madrid. España. @fgordo5

Vicent Modesto A; MD. Jefe Clínico UCIP Hospital Universitari I Politècnic La Fe. València, España.

Rodrigo Adasme J; MsC, Pt, CRT. Terapia Respiratoria Hospital Clínico Red de Salud UC-Christus. UNAB. Santiago, Chile.


This is a great review of 45 references to help us take care of patients with COVID-19. There is much left to be learned about this horrendous disease, but we can take cues from prior experience to help us guide our management of the ventilator to cause as little harm as possible. The group of experts listed above, using their multinational expertise, developed this evolving document including algorithms as well as guidelines that will be updated as we learn more. Best of all, it's free to us all. Thank you!

Link to Article

Link to PDF in English

Link to PDF in Spanish


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Proning patients on NIV or HFNC

Disclaimer: I am a consultant for a company mentioned in this paper but I am not being compensated in any way, shape or form for this post.

People have asked if it is safe to prone patients who are in ARDS and use either non-invasive ventilation or high flow nasal cannula. In this paper, which is completely FREE for you to download looked at 20 patients who were in ARDS (causes listed on the paper). This was not a randomized trial. It was an observational cohort. They included patients with with moderate ARDS per the Berlin Criteria.

Important teaching point is the Berlin Criteria for ARDS (PaO2/FiO2)
Mild P/F 200-300
Moderate P/F ≤200
Severe: P/F ≤100

Also important to know that moderate ARDS has a mortality of 32% and severe ARDS has a 45% mortality.

55% of patients avoided intubation (it's a small study). But when you consider the fact that these patients with COVID generally stay on the vent for more than 10 days anecdotally, require significant sedation and perhaps paralytics, and eventually move on to be trached, it may be worth consideration. 3 of the 9 patients who were intubated moved on to needing ECMO.

The short answer without me giving away any bias for the aforementioned reasons is that it could be done. The data supporting it is in this article. No, it is not a magic bullet. Not everyone will dodge the endotracheal tube. But one could start asking their patients to do this even in their Emergency Department.

Also, I cannot comment on the concern of aerosolization of the virus by NIV or HFNC at this juncture. I honestly don't know the answer. What I do know is that we may run out of vents if we intubate everyone early. Always wear as much PPE as you can reasonably get your hands on.

Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care. 2020;24(1):28. Published 2020 Jan 30. doi:10.1186/s13054-020-2738-5

-EJ
Link to Abstract

Link to PDF

Link to Berlin Criteria

Multiple Patients on a Ventilator: FAIL

Sometimes medicine behaves like the stock market; a whole bunch of enthusiasm followed by a realistic pullback. This has now occurred with the concept of using one ventilator for multiple patients. I agree that we need to use some ingenuity in this crisis, but this one never sat well with me, hence me not commenting on it at all until now. Too many nuances go into oxygenating and ventilating patients with ARDS. I understand trying this to hold down the fort in a severe crunch, and I tip my hat to those who created the articles and YouTube videos. I'm not trying to be a contrarian or a Debbie Downer.

This statement was put out by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (ASPF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST).

Amongst things mentioned here, all patients would need to be paralyzed for this to maybe work. What happens after the 48 hours of paralytics runs it course and they can't play nice on the vent anymore? One always needs an exit strategy. This is something I always teach when taking care of patients in the ICU. I digress, the list provided shows some other safety reasons.

We need to continue thinking outside the box, though, to save all the lives we can. I have never seen our community come together so well. We have done a great job supporting each other. Many have said it already and I agree with them, many of us are going to come out of this psychologically altered. Many of us are, what some would call, jaded in things of life and death. It's part of our daily lives in Critical Care. But this is taking that to another extreme. I appreciate the support that I have received from the community as well. Hope to keep providing you all with great content.

-EJ



Link to ASA Position Statement

Link to SCCM Position Statement

Link to PDF

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Prone Positioning for ARDS

I am a huge fan of proning patients who are in ARDS. At one point or another I'll cover the data behind proning like the PROSEVA trial (no time today or until at least June). There are a variety of ways to prone patients which reflect the disposable income of the facilities where you work and train. At the 3 institutions were I have worked and the others where I have done moonlighting shifts, we've all used some good ol' fashioned muscles and coordination.

The PDF quoted and linked here was published in December 2019 and is usually very key during flu season. I am not going to comment about the coronavirus but these patients are developing an ARDS-like syndrome where proning may work. I haven't seen any data, though. That being said, having the ability to prone patients and do it well could potentially save lives.

In the paper, they cover pretty much everything I would want them to in a document like this that's beneficial to all. They even discuss chest compressions and defibrillation in these patients, something we all fear.

The PDF is completely free and a direct link. I need to find out the citation for this bad boy. The authors did a great job and a big hat tip to them. There's a really nice safety checklist and nursing checklist included. 

How do you all prone at your institution?

Do you not prone at your shop because of fear of the tube coming out?

Have you ever had to perform CPR on a proned patient?




Link to FULL FREE GUIDELINES


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Dexamethasone in ARDS

This is a big impactful study. I'm happy it came out, really happy. To start off a big hat tip to my colleagues in España who put this together. ARDS sucks. It's a b-word to treat and patients spend a frustratingly long time to come off of the vent. Mortality rates are high. Morbidity rates are through the roof. Cost burden to the healthcare system is insane. The repercussions are unquantifiable. Many of these people never even return to work.

In my practice, when I have a patient with ARDS, I make sure to treat the underlying cause, protect their lungs with the vent, keep them as dry as humanly possible, and provide them with 4 days of vitamin C, hydrocortisone, and thiamine. The CITRIS-ALI study providing vitamin C showed a decrease in mortality in this population, less time in the ICU, and less time in the hospital (albeit with many caveats to that study). There's bench research that shows how vitamin C and corticosteroids are synergistic in preventing and repairing lipopolysaccharide-induced pulmonary endothelial barrier dysfunction. But we never had good data regarding giving these patients steroids to begin with. In theory it made sense, but we needed more help. We were simply doing our best and shrugging our shoulders in many of these cases.

Enter the DEXA-ARDS trial. They randomized patients with moderate to severe ARDS to either get dexamethasone or placebo. Note that they give the first dose immediately after randomization, something that they waited 12+ hours to do in the VITAMINS trial. I digress. Not bitter. Okay I'm bitter. Nonetheless, the pts who got steroids did better. They came off the vent quicker and had fewer deaths. Both statistically significant. One of the key takeaways regarding the vent free days is that we start thinking to trach pts around day 10-14. The dexamethasone group got off the vent around day 14. The control group around day 20. How many trachs were spared and the morbidity that comes with that? It's not specified in the article but I'm curious. Another key piece is the fact that there was no increase in side effects of the steroids.

Ultimately this trial is changing my practice. I was perhaps stopping steroids too early in the past.

-EJ



Villar J, Ferrando C, Martínez D et al. Dexamethasone treatment for acute respiratory distress syndrome: a mutlicentre, randomised controlled trial. Lancet Respir Med. 2020; (published online Feb 7.)

Link to Article (NOT FREE boooooo!)

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Non-Invasive Ventilation Algorithm

Not every patient reads the textbook, but you and I have to know where to start when managing our patients who have hypercapnic respiratory failure that we want to treat with non-invasive ventilation (or what you and I frequently call BiPAP). This algorithm is taken from the British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guidelines that were published in 2017. Fortunately, they are free for you to download your own copy and put it up on your wall. 

This guideline recommends starting with an EPAP of 3. If I'm honest, everywhere I've been and the way I've been trained is to start at 5. Also, they recommend uptitrating the IPAP up to 20-30. In my practice, once I start kissing 20, I start thinking very seriously about intubating the patient. 

For those who are unfamiliar with the kilopascal units (as I certainly was), the equivalent PCO2 is 48.75mmHg. Note that you need to have acidosis and hypercapnia in COPD exacerbations to have any benefit from NIV. 

A hat tip to the authors. 

Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71 (Suppl 2):ii1–35.

-EJ






Link to Article with FULL FREE Algorithm

Ghosh D, Elliott MW. Acute non-invasive ventilation - getting it right on the acute medical take. Clin Med (Lond). 2019;19(3):237–242.



Link to the FREE FULL Guidelines

Davidson AC, Banham S, Elliott M et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71 (Suppl 2):ii1–35.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

High Flow Nasal Cannula in Acute Decompensated Heart Failure data leaves much to be desired.

Fortunately in the critical ill population, we do not necessarily have to abide by the saying that "if all you have is a hammer, everything looks like a nail". What I'm referring to is regarding utilizing high-flow nasal cannula in acute heart failure exacerbations. I already dissected how HFNC generated a "PEEP" equivalent airway pressure and the data behind that statement. The amount of PEEP varies and it drops by a statistically significant difference if the patient has their mouth open. If a patient presents to the emergency department, or someone gets overzealous with maintenance fluids, with an acute heart failure exacerbation, there is data that I will be reviewing here where HFNC is an option. But let's be honest with ourselves, though, non-invasive ventilation (colloquially known as BiPAP, although CPAP has data for working as well) is the better option because it provides positive airway pressure more reliably that HFNC. Sometimes these patients just need the ventilator as well. All three studies are FREE that I am going to be reviewing here and I recommend you read them for yourself rather than trusting my takedown of them. That's your disclaimer.

The first study published in 2011 out of Spain was a look at just 5 patients. I know, don't fall off of your seat. I can't criticize because I don't do any research outside of read other peoples research. One needs to remember that in 2011 the HFNC systems were not readily available for historical context. These 5 patients were treated in the emergency department with NIV and then I guess they were diuresed aggressively there. Why do I guess? Well the study does not report the BNP nor the achieved diuresis in these 5 patients. Big weakness in the study. They looked at a multitude of parameters that would be standard for a study of this nature, i.e. to see if HFNC is better than the other oxygen devices, but there are big problems. You see, the authors looked at the parameters before HFNC and then 24 hours AFTER HFNC. What they don't say is how much the patients were diuresed in the interim. Of course the PaO2 is going to improve. Of course the dyspnea is going to improve. Of course the respiratory rate is going to improve! Anyway, this is a study worth sticking in our back pockets to know it happened and move forward.

The second study by Roca also out of Spain in 2013 wanted to assess if HFNC helped with the hemodynamic parameters. They hypothesized that HFNC in patients with heart failure could be associated with a decrease in preload without changing the cardiac output. To look at this, patients got sequential echo's to assess cardiac function. Pretty good setup if you ask me. The 10 patients enrolled in this study were all stable. Therefore the data needs to be extrapolated to the sick patients. They did a baseline TTE on these patients, then hooked them up to the HFNC system at 20L, checked an echo, then at 40L of flow, and checked an echo. They did all sort of echocardiographic wizardry to obtain their results. They found that HFNC may be associated with a decrease in preload justified by the lack of IVC collapse on inspiration without any changes to cardiac function. IVC measurements are their own can of worms when used for resuscitation but this is very standardized and methodical. The most interesting finding that I enjoyed was the decrease in respiratory rate noted by these patients. At baseline, their RR was 23 breaths per minute. At 20L this fell to 17 bpm. At 40L this fell to 13 bpm. Cool stuff! Note that the patients were receiving just flow in this study as the FiO2 was set to 21% (room air). The authors chose to not use patients in acute decompensated heart failure for this study as there would have been too much variability in the subjects themselves along with their responses to the treatments interfering with to the measures. Obviously if they dump out a liter due to furosemide their hemodynamic parameters are going to change and it'll mask out the effect of the HFNC or provide confounders.

The third and last study I'm going to share with you all today comes from our colleagues in South Korea who performed a retrospective cohort analysis where patients were divided into a HFNC group or an intubation group after oxygenation with a facemask at a flow rate of 10L/min or more. These authors jumped on the opportunity to look at this data as they hadn't seen any published data about using HFNC in patients with acute heart failure exacerbations. They looked at approximately 5 years of data to place 73 patients in the intubation group and 76 patients in the HFNC group. Since this was a retrospective study, the decision as to what arm the patients fell in was at the discretion of the physician at bedside. The authors are just looking back in time at why they decided to do it and how the patients did. It seems as if they ignored the NIV data. I could be wrong. The baseline characteristics of the two arms were similar with nothing too eye catching. These patients were looked at for 6 hours. There were no statistically significant changes in the physiologic responses between the two groups. There was also no difference in the clinical outcomes between the two groups. This oddly, in my opinion, includes vasopressor/ionotrope use. I mention this because patients who are intubated typically have sedation. Also, the medications utilized for intubation could have an effect on hemodynamic parameters that are not noted here. It's just something that, from a personal experience standpoint, has me a bit curious. The p-value for that is 0.051. If the sample size would've been larger, I'm sure that would've been a notable difference. The authors noted all these limitations to their study and agree that what we really need is a prospective, multicentered, randomized, controlled trial. I agree

To conclude, I think the best we have right now in the absence of concrete data is clinical judgment, my favorite. One could try to place the patient on HFNC to either keep them away from the ventilator or even keep them from being annoyed by the CPAP/BiPAP mask which is typically uncomfortable, limits the ability to eat, speak, and other fun activities. If it fails, it fails. Your RT may be a little annoyed at you and may say "I told you so", but ultimately we have to do what's best for the patient. Thoughts? Please read these articles for yourself. A hat tip to all the authors. 

- EJ





Link to Abstract

Link to Full FREE PDF



Link to Abstract

Link to not free PDF




Link to Abstract

Link to Full FREE PDF

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Helmet vs Face Mask NIV for ARDS

I originally posted this article on 6/21/19 while preparing my NIV/BiPAP lecture. During that process, I learned and shared on IG about using a helmet rather than a mask for NIV (non-invasive ventilation). Looking at the footage that has been coming out of Italy and other parts of the world, you can catch a glimpse of their pumps, ventilators, and in the case of this post, the fact that many institutions are using the helmets.

Why are these places using helmets instead of face masks and what does the data say?

The study I am referring to was published in JAMA in 2016 and they compared utilizing a face mask vs a helmet setup in patients with ARDS. The study was actually stopped early because the data was so good. They were trying to get to 206 patients but stopped at 83.

The authors found that patients who wore the helmet were intubated less frequently, 18.2% vs. 61.5%, had more ventilator free days, a shorter length of stay in the ICU, and lower both in-hospital mortality and 90 day mortality. Patients were also on NIV with the helmet for a shorter period of time utilizing less PEEP, less pressure support, and required a lower FiO2.

Could the helmet be a tool to help out to minimize the need for intubation and mechanical ventilation? Does anyone here have experience with the helmet setup? This study was created in Chicago, I'm sure there's has to be someone around here who was at that institution while this study was being performed.

-EJ

Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2016;315(22):2435–2441. doi:10.1001/jama.2016.6338

Link to Article

Link to FULL FREE PDF

Link to PDF (Backup)




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High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure: A Review of the FLORALI Trial

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

I first shared this article in June of 2019 on Instagram when my account had a mere 2500 followers. Since then the amount of followers to my account have skyrocketed and I could not have done it without the help of each and every one of you who find value in what I do.
As an aside, many of you know I'm preparing a lecture on high-flow nasal cannula and non-invasive ventilation. This article is one of the landmark trials in the HFNC literature and it's worth revisiting in greater detail. After all, I wasn't taking articles apart in as much depth several months ago as I am now. The name by which this study is commonly referred to is the FLORALI trial, as in high FLow Oxygen therapy in Resuscitation of patients with Acute Lung Injury. Witty, huh? The authors had noted that there weren't any studies looking at non-invasive ventilation in patients who were in acute hypoxemic respiratory failure that were not hypercapnic. They went ahead to detail all the beneficial effects of HFNC which I have beat you all over the head with on this medium. They went ahead and designed a prospective, multicenter, randomized, controlled trial to see which worked best to avoid intubations and improve outcomes in patients who were in hypoxemic respiratory failure: NIV, HFNC, or standard oxygen therapy which I will herein refer to as SOT.
They chose to enroll patients who were sick, but not too sick. After all, you need to enroll patients and keep them safe at the same time. If you choose patients who are too sick, then clinicians aren't going to follow the study protocol. They had a strict protocol as well to intubate patients so that patients wouldn't be left lingering without being intubated. After all, there is clear data that if you wait too long to intubate, patients do poorly and there is increased mortality. They included patients who were hypoxemic with a PF ratio < 300, needing a flow of 10L, a PaCO2 < 45 (so no COPD exacerbation patients here) and no chronic respiratory failure. Asthmatics were also excluded, as well as cardiogenic pulmonary edema, use of vasopressors, and hemodynamic instability. They had other parameters but you can check out the article for yourself.
Patients were randomized at 1:1:1 for SOT (nonrebreather at flow of 10L), HFNC (50L of flow and FiO2 titrated), and NIV (pressure support titrated to obtain a tidal volume of 7-10cc/kg ideal body weight and a PEEP between 2-10cmH2O).
When you look at the characteristics of the patients enrolled, and they enrolled 310 of them, the vast majority had pneumonia with a predominance of community acquired followed by healthcare associated pneumonia.
The primary outcome was rates of intubation. There was no difference if you just look at the direct comparison p-value of 0.18. When you look at the patients who had a PF ratio less than 200, though, the patients with HFNC did MUCH better with p-value of 0.009. This is your indication, team! You have someone with pneumonia, don't put the on NIV when HFNC may work better!
Fewer patients died in the ICU if they were to receive HFNC versus the other two (p=0.047).
There was also improved 90 day survival in the HFNC group (p=0.02). This was enough info, and more in the article that you really should read for yourself, to convince many ED and ICU practitioners that HFNC is the way to go in this patient population. Check the article out for yourself!

- EJ





FREE FULL PDF with an account

Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.; FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–2196.

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Airway pressure release ventilation (APRV) during acute hypoxemic respiratory failure

Link to Article

link to full FREE PDF

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