March 31, 2020

I have been thinking a lot about patients with COVID-19 and the pulmonary pattern that they develop.  This disease process has been categorized like ARDS, but the reality is it is not ARDS.  Lung compliance is often normal in these patients, and many patients are not in respiratory distress despite low O2 saturations.  Patients can have a bizarre hypoxemia that does not correlate with their symptoms.  I have even read reports of patients looking comfortable and speaking in full sentences with oxygen saturations in the 40 – 80% range.  There are also more traditional patients in respiratory distress with similar oxygen saturations.  This is a situation where we cannot treat a patient based solely on a number - pulse oximetry may not be a reliable marker of respiratory compromise.

Approaches to oxygen supplementation have stressed minimizing aerosolization of viral particles by avoiding HFNC and NIV.  This appears to be a fear-based statement as opposed to an evidence based one.  If we go straight from nasal cannula to intubation, we will simply run out of ventilators.  Then, more challenges present themselves like rationing mechanical ventilation and trying to figure out how to split ventilators due to the lack of resources.

Finally, I have yet to find a study that shows a mortality rate <50% once a patient is intubated.  Maybe a better way to deal with these patients is an intermediary step using HFNC or CPAP while proning patients while they are awake, before considering intubation.  In this post, I want to review some evidence to support my thoughts on this and, just assume that in every scenario we are discussing full PPE (eye protection, N95/PAPR, gown, gloves, and face shield).

March 21, 2020

Background: Since the introduction of SARS-CoV-2 to the world in December 2019, there have been no medications approved or proven effective for the treatment of this pandemic. Lopinavir is an HIV protease inhibitor that is combined with Ritonavir to increase its half-life.  This combination of medications has also been studied in severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) and showed promising results. This makes it a research target for COVID-19.  Many of us are awaiting a treatment that works against SARS-CoV-2 and badly want/need a treatment that is safe and effective. In this publication the authors evaluated the efficacy and safety of oral lopinavir-ritonavir for SARS-CoV-2 infection in adult patients hospitalized with severe COVID-19.

March 20, 2020

On Feb 21st, a patient by the name of Aldo, a 72-year-old male, came to our ED with fever and progressive dyspnea. In addition, his chest x-ray showed an interstitial pattern. It was on this day that COVID19 had arrived in our emergency department… In this post we will describe how we responded to the COVID19 challenge, the impressive number of patients seen in just a few days’ time and some suggestions to prepare your emergency department for the future.

March 12, 2020

Background: Most published clinical guidelines on the management of primary spontaneous pneumothorax (PSP) advocate for a conservative approach of observation for small asymptomatic pneumothoraces (PTX).(1,2) However, procedural re-expansion with a catheter or chest tube is recommended for all large pneumothoraces, regardless of symptomatology or clinical stability.(1) More recently, smaller chest tubes (i.e. pigtail catheters) have been used as this can potentially cause less pain. Typically, patients who get chest tubes or pigtail catheters require hospitalization for management of the tube. But, chest tubes are not without risk: there are multiple reports in the literature describing terrible consequences of chest tubes including bleeding, infections and empyemas, and misplacement into vital organs like the liver, spleen, and heart.(3-5) An alternative approach to this invasive procedure is to do nothing, unless the pneumothorax becomes physiologically significant. In an effort to reduce these risks and discomfort to the patient, the clinical quandary becomes: can a large pneumothorax be managed using a conservative observation-only approach, without placement of catheters or chest tubes? To date there have been no randomized clinical trials comparing these two polar opposite management strategies until now (The PSP Trial).

March 9, 2020

Background: Oxygen therapy is frequently used in the emergency department for the treatment of hypoxia and respiratory failure and can be delivered in a variety of ways. Conventional oxygen therapy (COT) via nasal cannula is often a first line treatment, but has some drawbacks, including inability to deliver a precise concentration and volume of oxygen, inability to deliver high enough concentration and volume of oxygen, inability to heat and humidify, and poor tolerance.  While it is able to deliver more precise, high flow oxygen, noninvasive ventilation (NIV) also presents a comfort challenge for many patients. High flow nasal cannula (HFNC) has been introduced as an alternative to COT and NIV. It can be used to deliver heated, humidified oxygen at high rates (up to 60 L/min) and maintain a set oxygen fraction. Prior randomized controlled trials (RCTs) and meta-analysis comparing HFNC to COT and NIV have demonstrated conflicting results. Additionally, none of these previous meta-analyses have evaluated emergency department (ED) patients.