May 1, 2020

Background: Over the past few weeks there has been a shift in the management of critically ill COVID-19 patients.  Many seem to have moved away from an intubate early strategy to the use of high flow nasal cannula (HFNC) and noninvasive ventilation (NIV).  HFNC and NIV may obviate the need for endotracheal intubation in patients with acute respiratory failure.  Mechanical ventilation is not a benign intervention as it has a number of associated complications including ventilator associated pneumonia, excessive sedation, delirium, ICU acquired weakness, as well as ventilator induced lung injury (VILI). NIV can cause lung injury from excessive negative pressure forces.  However, mechanical ventilation can cause VILI from excessive positive pressure forces.  There is a fine balance of when to use which modality, and when to transition from one modality to another that requires frequent bedside monitoring.  NIV has been used successfully for COPD exacerbations and cardiogenic pulmonary edema, but its use in acute hypoxemic respiratory failure is still rather controversial.  One of the issues with NIV through a mask device is that higher levels of positive end-expiratory pressure (PEEP), which are often needed in hypoxemic conditions, may lead to mask intolerance and air leaks around the sides of the mask.  Helmet NIV may have several advantages over face masks including better tolerability and less air leaks.  There is a dearth of evidence comparing these to NIV modalities.

April 30, 2020

Background: Currently, there are no approved medications for the treatment of COVID-19, but,  there are many investigational agents that have shown antiviral activity against SARS-CoV-2 in vitro.  Unfortunately in vitro studies do not always extrapolate to clinical care  In vitro studies of remdesivir demonstrate inhibition of  human and animal coronaviruses tested including SARS-CoV-2.  However, the clinical and antiviral efficacy of remdesivir in COVID-19 remains to be established. The title of this post is, "two more trials just published on Remdesivir," but in reality it is 1.5 trials as we don't have the full release of the 2nd trial (see discussion).

April 29, 2020

Needs Assessment: As the COVID19 pandemic continues to mount, hospitals will rapidly reach maximal capacity. As a result, patients are boarding longer in the ED and, new patients are waiting longer to be seen. This dynamic poses numerous threats to patients safety. While we are seeing a large number of patients with severe and critical COVID19 who require intense monitoring, therapy and even ICU resources, many patients are only in need of supplemental O2 while they deal with their symptoms. The ability to discharge patients home with O2 and proper follow up monitoring can help open up more beds in both the ED and the hospital in general allowing us to deliver the proper resources to patients who need them.

April 28, 2020

Early reports have shown that COVID-19 is most likely causing a hypercoagulable state, however the prevalence of acute VTE and exactly how to treat it is an evolving area.  Limited data suggest pulmonary microvascular thrombosis may play a role in progressive respiratory failure.  However, most evidence is limited to small retrospective trials.  As we wait for more evidence, clinical decisions have to made at the bedside and decisions about pharmacological prophylaxis are starting to emerge.  In this episode I sit down with a special guest that is new to REBEL Cast to talk about the dilemmas involving COVID-19 and thrombosis.

April 26, 2020

Background: Awake proning, or having patients lie on their stomachs, can help oxygenation by helping to recruit posterior portions of the lungs and by helping with perfusion to oxygenated lung segments. The literature around proning centers on intubated patients with adult respiratory distress syndrome in the ICU. However, there are increasing recommendations from front line clinicians and experts about the benefits of proning hypoxemic COVID19 patients who are awake in an effort to improve oxygenation and stave off intubation. While there may be physiologic reasoning, anecdotal experience and application of data from intubated patients, there is an absence of data specifically on COVID19 patients and proning. Fortunately, we now have some literature to look at: