Hello, and welcome to today's COVID-19 Q&A call. This is the first of six in a series of COVID-19 Q&A calls. Welcome to the webcast. My name is Pedro Salinas, and I am an intensivist at Aurora Advocates and Luke's Medical Center. I'll be moderating today's webcast. This webcast is being recorded. The recording will be available to registrants within 24 to 48 hours. To access, please go to covid19.ccn.org. Thanks for joining us. A few housekeeping items before we get started. To submit questions throughout the presentation, type into the question box located on your control panel. Please note the disclaimer stating that the content to follow is for information or educational purposes only. And now I'd like to introduce your speakers for today. Dr. Kunal Karamachandani is the medical director of Anesthesia ICU and associate professor in the Department of Anesthesiology and Perioperative Medicine at Penn State Medical Center in Hershey, Pennsylvania. Dr. Christopher Howard is the medical director for respiratory care at CHI, Baylor-St. Luke's Medical Center, and assistant professor of medicine at Baylor College of Medicine in Houston, Texas. Captain Ram Stevens is an intensivist at Aurora-St. Luke's Medical Center and professor of anesthesiology and medicine at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois, and COVID task leader for Aurora-St. Luke's Medical Center and Aurora Advocate Health System. And now we'll get right to it with questions from our attendees. So the first questions that we get from the attendees is, what are your thoughts about using glucocorticoids in patients with severe ARDS, secondary to COVID-19, who remain intubated after seven days? Dr. Stevens, would you like to start? Dr. Salinas, Dr. Stevens here. The CDC in the medical letter have both recommended against use of corticosteroids because it's possible that they could prolong viral replication. They are recommended by the SCCM and surviving sepsis campaign for treatment of refractory shock. However, I believe that there's insufficient data in the scenario of respiratory failure in COVID patients. That's all. Anyone else would like to comment? I would agree. I don't think there is any specific data as of now about use of... This is Dr. Chandani and again, thank you for the opportunity. So upon reading and upon especially the SCCM guidelines as well, it doesn't appear like there is any concrete evidence that glucocorticoids be used just because of ARDS. Now, if you have refractory septic shock consequent to COVID, then there is an indication just like you would for any other cause of septic shock. Just for ARDS, I don't think there is any specific recommendation as of now. This is Chris Howard. One thing that we've seen on a couple of patients that they, even after intubation and development of disease, they start to develop airway obstruction on the airway mechanics in the vent. And we tend to kind of lean more towards and favor on those specific patients only. But as a general rule, I think it seems like most seem to be avoiding steroids. Okay. Matthew Meyer is asking, have the speakers taken direct care of COVID positive patients? Dr. Stevens, yes. Yes. Dr. Howard. This is Dr. Karam Chandani. So, I mean, I'm being involved with the planning and talking to the MIECHV colleagues. Ours is a tiered approach in the sense that we have teams, so the COVID-1 and 2 teams are staffed by Palm Critical Care, the COVID-3 team would be staffed by Anesthesia Critical Care. So, I haven't taken care of them directly, but I've been in regular touch with our pulmonary colleagues that have been taking care of them, as well as making hospital-based guidelines for how we need to work on this. Yeah. Another question is, what are the current evidence for PPE recommendation and some of the conservation strategies? Dr. Stevens. I'll go ahead and answer that question. Now, as far as, you know, PPE, that's a very controversial, I mean, I wouldn't say controversial, it's a pretty hot topic right now, and especially in the setting of the limited resources that we have regarding PPE in the country. Now, what has been specifically recommended is that any kind of a procedure that involves aerosolization, which includes endotracheal intubation, bronchoscopy, disconnecting the ventilator for, you know, any reason whatsoever, those procedures, like, would warrant an N95 or a mask of that extent. I think Europe has different guidelines, but for most of the people here, it's either N95 or if you're not a mask-fit person, then a PAPR. So that is a recommendation that has no, you know, that's a strong recommendation. Now, as far as the other part to it is, if you're not doing any aerosolizing procedures in these patients, for example, if a patient is already intubated, connected to the ventilator, and you're putting in a line, or if you're doing some stuff in the ICU, what is recommended is that if you have your resources and you can, you should use N95, but if you do not, then droplet precautions with a surgical mask and a face cover and an eye shield is, you know, is probably good enough. But again, it's more of a resource-based thing. So I would say one thing is clear, if it's a procedure that involves aerosolization, you have to have an N95 or a PAPR. If it does not involve aerosolization, then you can use a surgical mask with your eye cover, and that should be okay, based on the recommendations that have come out. Dr. Stephens here, I'd like to respond. I think that the recommendations that we have now are based on the experience with the SARS-Corona outbreak in China in 2003, I believe, and there were a number of nosocomial transmissions and healthcare workers being infected who were not, particularly anesthesiologists, that were not using N95 masks during intubation. And I believe that that data from a 2006 paper have influenced the current recommendations by the CDC. So there are many related questions. So is there anything else that the panelists would like to add in terms of the best way to read these N95s about sterilization procedures? Yeah, this is Chris Howard. Kind of on a semi-related note to at least conservation of PPE, we've had a lot of really creative nurses and doctors come up with solutions. I think these have probably been shared among multiple institutions, but one thing I found particularly helpful is using extension tubing for IV pumps so that the nurses can control IV pumps outside the room. We've done the same thing for CRT, and then I've been working closely with a lot of our team members specifically about our ventilator panels, our control panels. We can actually extend them to be outside the room while the vent stays inside the room. This has been kind of a game changer in my experience. It reduces your visits significantly, especially working on ventilator adjustments personally. When you're not having to go in and out of the room every single time to troubleshoot vent problems, it really makes a huge difference in terms of the quality of care and the frequency of care you can provide without having to reuse or run through your supplies of PPE. So any other comments about... There's a lot of questions about airway management, instrumentation, and protocols for intubation. Any other comments about that? And also there's been questions about using one ventilator for two patients. So I can talk about the airway part since we just formulated our airway policy and we just intubated one patient last evening. So I think, as I said before, airway manipulation, whether it's intubation, it's a pretty high-risk procedure. So any person who's going in to do these airway procedures, whether it's intubation or bronchoscopy, needs to have an N95 mask, a face shield, a hat, a gown, and full PPE for this procedure for sure. And again, a lot of things which probably people already know, but it's very important to make sure these guys are pre-oxygenated well because you do not want to do a bag mask ventilation in these patients because there's a very high risk of spreading aerosols around. So one is protective gear for the people who are going in to do the procedure. In our institution, we have two people go in depending on how the airway looks like and what they feel like the logistics would be. And so they go in and they use pre-oxygenation. Videolaryngoscopy is what is recommended and not for anything else, but just because you're not as into the, you know, in letting the scope to intubate, you can actually visualize from a little bit further away. So just reducing the risk of the personnel who's doing the procedure from getting aerosolized. Again, the most experienced provider who's familiar with airway should be doing this because this should be as short of a time you can take to put the breathing tube in should be the goal at this time. Again, as far as whether cricoid pressure or not, there's not much data on cricoid pressure in general. So again, if you feel like the patient is full stomach, you can use it. But again, I don't know if there's any concrete data on that. Now as far as once the tube is in, you know, and the cuff is up, after that, you connect it to an Ambu bag and make sure you're in the right place with your end tidal monitoring. The other thing to be careful with that is make sure you have a filter attached to the Ambu bag. And once you've confirmed and you're happy, then, you know, clamp the tube and then hook the tube to the ventilator. I think that's the sequence of events. Now, if you run into a difficult area, of course, you follow the usual difficult airway algorithm. And that's why having two people there would be reasonable. If you look at the literature of fiber optic intubations are usually not recommended for these patients. And if you run into trouble, I think a front of neck access is another thing to consider. So you can have all these resources in the ante room, which should be next to your room where you're intubating and then you can ask for them. But that in a nutshell is what we have kind of made our, you know, way of manipulating airways and doing intubation in these patients. In a related question, do you have a specific threshold for intubation since there's been a lot of you mentioned about these patients rapidly decompensating? So here's what we actually just had a discussion this morning about this. So what we have seen is that, you know, whether you give them oxygen at two liters or six liters, their PaO2 does not budge much. And I think for us, it's been, you know, we, the max we have gone in our institution is six liters of nasal cannula. And if the PaO2 has not responded, we just go ahead and prepare for intubation. And the key is to be prepared sooner rather than later. And so that this intubation is not an emergent intubation, but you have time to prepare and so on. The other thing which is pretty, you know, well, you know, it's been discussed and is about the use of high flow nasal cannula and all the ways of ventilation in these patients. So that's another area of, you know, kind of not clear evidence. Now, if you look at non-COVID ARDS patients, you know, using high flow nasal cannula has been found to be effective in some studies in preventing intubations. But in COVID patients, the risk is with the high flow, you have a high risk of disseminating the aerosols and kind of contaminating the area you're in. So, but what I was reading in the WHO guidelines, again, a lot of places do not recommend using high flow and non-invasive, but the WHO said if you have to use it, you can use it for less than an hour. And if you're not getting the results that you want and you don't have improvement in your PaO2 or if within putting the high flow nasal cannula on, you see that there is deterioration, it's better to go to intubation sooner rather than when you have extremely hypoxic patients getting intubated. And at your institution, do you have two people inside the room? So, we have two people that can go in. So, our airway team comprises of three people right now. One is a house staff member who is not going into the room at all, but is there outside to help out. Then we have a certified registered nurse anesthetist and attending physician or a faculty anesthesiologist that are part of the airway team. And it's amongst them that they decide if they feel like this patient would need the both of them in there or if they feel like there is one person is going to be okay. That's a decision that the attending anesthesiologist and the CRNA on the airway team make. Excellent. Dr. Stephen, I'd just like to make a comment, if I could. In the face of the COVID epidemic, we are still faced with care for patients who have respiratory complaints, who are persons under investigation, but ultimately turn out to have acute exacerbation of COPD. And those patients will likely still benefit from BiPAP. So, in our institution, we have developed a protocol to allow for BiPAP in those patients as long as it's done in negative pressure rooms and or in rooms that have a HEPA filter placed. Because we're all focused on COVID, but we still have other respiratory issues that we're dealing with in light of the influenza A epidemic and the fact that it's winter in the northern hemisphere. This is Chris. I'll just to round up the discussion. This is a really tough topic, whether you use high flow and or NIV. Our practice so far kind of reflects what SCCM is looking at in terms of kind of leaning more towards favor of hyponasal cannula. Once we hit about 30, 40 liters of flow, though, and we're maxed out on our FO2, we go ahead and we'll probably intubate those patients. And we are generally avoiding NIV unless there's some sort of exceptional circumstance. So, that's generally kind of our protocol and practice pattern so far. We've had some pretty good luck with that. So, there are a lot of related questions. Is there any recommendation regarding health care workers in a COVID ICU with proper PPEs living in the same household? I don't think there are any official recommendations. I think there are a lot of people who are in the same household, but I don't think there are any official recommendations. I'm not familiar of any official recommendations about health care workers and, you know, when they're done with how they interact with their household. I think social distancing is the key, but beyond that, I don't know if there is. I mean, you know, there are certain, you know, on social media, there's a lot of stuff about when you come in, keep your, you know, stuff out as soon as you come in, put your clothing in the washer and go take a bath and so on. But again, I don't know if there's anything which has concrete evidence behind these. All great things to kind of limit the exposure that you can, but again, I don't know if there's any, like, evidence-based recommendations of that. Okay, there's also, in terms of mechanical ventilation, any comments on that? Okay, there's also, in terms of mechanical ventilation, any comments? There's a question about the limit on PEEP and plateau pressures. Any comments on ventilator management? Dr. Stevens, I would comment, based on the information that we're getting from our colleagues in Italy and China, and again, this is not peer-reviewed, but we believe accurate, that I believe Professor Gattinoni actually published a letter recently suggesting that patients with COVID respiratory failure who develop ARDS generally have higher than normal compliance or higher than other ARDS states' compliance, and therefore, high pressures are not being required. And in addition, proning and pulmonary vasodilators appear to be helpful. This is Chris. We've actually seen actually kind of a mixture of that picture. I've seen Dr. Gattinoni's letter. I think it's been circulating for the past week or so. So yeah, we've actually seen some with very kind of normal-ish compliance, but we've also seen kind of that standard bread-and-butter ARDS, low compliances, and we're having to be very careful about low tidal volumes and extremely low, ultra-low tidal volumes in order to achieve those plateau targets. SCCM guidelines mention plateau pressures of 30 or less. That's pretty standard for ARDS. We're also trying to achieve low driving pressures, 15 or less as well. Other than that, I think we're just pretty much kind of going with what we know in terms of treating ARDS the way we do it according to SCCM and previous guidelines. There haven't been too many nuances that have popped up in terms of evidence and how to change that otherwise. There's a related question about the role of APRV in COVID patients. Yeah. Again, APRV specifically doesn't really exist in SCCM or any kind of any other guidelines. It's a popular mode to use as salvage mode. We actually, as a practice pattern, not necessarily as a strict guideline on protocol, we tend to, once we get to the point of using APRV, what we're typically paralyzing, proning, and referring for ECMO, if ECMO or if any of those options are not going to be available to patient, we'll certainly use APRV as a salvage mode, but we don't use it routinely since we're typically moving on to other modes of support and ventilation. I think that's in accordance with the SCCM guidelines regarding mechanical ventilation, low tidal volume. I would like to move into aspects of triage and staffing. Can you comment about your institution or organization triaging of patients to the ICU? Dr. Stevens, would you like to comment? Yes, sure. Yes, sir. We have been working in Milwaukee very closely with our ED doctors and hospitalists, and we've developed systems for rapidly assessing patients in respiratory failure and then moving them either directly to the COVID ward or to the ICU, whichever appropriate, based on conversation between the attending ED doctor and the intensivist. Currently, we have not nearly exceeded our capacity in Milwaukee. I realize New York City, Milano, Bergamo are in different situations than we are, but we have been trying to remove barriers in getting the patients admitted rapidly to the ICU if they need ICU-level care, because we don't want those patients to be in the emergency department any longer than they have to. Would you like to comment about the patient search projections and how do we expand ICU coverage and staffing models? Yes, I can comment on that. In our organization, we have been looking at expanding our ICUs. In some of our hospitals, we have ICUs that have been downsized over the years and have existing rooms that were previously ICU rooms that were repurposed to wound clinics and pain clinics and other ambulatory surgery clinics. Those ICUs now are being refurbished by their hospitals and being re-equipped with monitors and ventilators and beds to prepare for a surge. In addition, our next line of surge capability would be to open up ICUs in PACUs. Because our organization, as many others have, have stopped doing elective surgery, we now have the luxury of having PACUs available, which have pipe-to-oxygen air and suction, have monitors, and are located close to nursing stations that have computer support and have trained PACU nurses and anesthesiologists available. And so our next maneuver would be to open up the PACUs. We have not as yet required to do that in Milwaukee. Same here in Pennsylvania as well. We haven't had a surge yet, but what is predicted is, I think, again, I think there was a prediction for every state, and I think we are in the mid-April kind of a stage for the surge that is predicted. Yeah, here in Texas, it's a similar thing. Immediately, what we started to kind of formulate options are personnel in beds, kind of as was Dr. Stevens mentioned before. You know, since elective surgeries have been canceled, that has slightly freed up some of our surgical ICU colleagues. So we're starting to use some of their units as COVID units, and they're staffing some of those patients. Also, we have some pulmonary clinic colleagues who are no longer doing the same amount of intense clinic work, and they've also been able to help out as well. It's actually been encouraging to see our colleagues kind of step up. It's really helped boost morale, I think, at least me personally, to see everybody kind of step up and help where they can. Dr. Salinas, I'd like to tag on to Dr. Howard's comments. We have also reached out to our pulmonologists and to our cardiologists colleagues at St. Luke's Medical Center in Milwaukee. We have a very large cardiology fellowship, and we've reached out to their fellowship director who's asked for volunteers, and a number of the cardiology fellows have rogered up to work in our ICUs, which I anticipate to be very helpful. And we have made them all aware of the SCCM website, the SCCM website that has training materials and a modular training program to train non-intensivists to work in the ICUs. Yeah, we're doing something similar. So, as I previously said, so we have, you know, we have medicine, pulmonary critical care, anesthesia critical care, surgery critical care, neurocritical care, and cardiology critical care. So, you know, we're kind of, again, coming together, merging our resources, and, you know, the first plan is to have the intensivist, but then we have already made plans to credential our surgeons and anesthesiologists in case we need to have them staff maybe our regular ICU patients, not the COVID ICU patients. So, again, a lot of surge planning is underway, and I think it's better to be prepared. So, you know, like, you know, we're already thinking of, you know, teams to take care of patients 20, 30, 40, 50 as they come in. And, you know, in central Pennsylvania, with the density not being that high, we haven't seen that surge yet. But, again, we're preparing for in case, you know, we get that surge in mid-April, we have plans in place to staff and use, you know, your non-intensivists, like, you know, your anesthesiologists, general surgeons, and kind of give them the resources. I think SCCM's resources are pretty helpful. I think they have some videos that they shared out, critical care for non-intensivists. And the feedback that I've gotten from the faculty that I have sent it to, who are general anesthesiologists, has been pretty positive about those resources. Okay, thank you very much. It seems that across these two different systems, we haven't reached capacity. But we're preparing for the surge of patients. There are many questions regarding the treatments. So I would like to start with the questions regarding the use of hydroxychloroquine and acitromycin, both for treatment, and also, is there any role for prophylaxis? And when are we using them? Dr. Stephens, I'll start. So the medical letter has just come out with a publication reviewing all the drugs that would have been suggested or recommended by our European and Chinese colleagues. Chloroquine and hydrochloroquine are, of course, FDA approved, and we're not going to be using them. Chloroquine and hydrochloroquine are, of course, FDA approved for prophylaxis and malaria and treatment of rheumatoid arthritis. They're being used off-label for treatment of COVID patients, based on preliminary data from China and France, showing that these drugs can reduce viral load and shorten the duration of symptoms. There's one open-label study, 42 patients hospitalized in France, showing the addition of azithromycin to hydroxychloroquine resulted in a more rapid decrease in viral load compared to treatment with hydrochloroquine alone. There are ongoing clinical trials evaluating the efficacy and safety of these drugs and interaction with other drugs, particularly those that also prolong the QT interval. But I would say the jury is out yet, and at least in our small N in Milwaukee, we have not seen a huge difference in the patients that we've treated with hydroxychloroquine. This is Chris Houdigan. I think what I've noticed observational among our institution and others is a lot of enthusiasm for using hydroxychloroquine and azithromycin. I think largely because the safety profile in our experience with them is generally pretty good and that they're easily well tolerated. With some of these other investigational medications, there's still a lot of mystery as to what the safety profile is. I think like a lot of places, our protocol for this is transitioning and kind of always a moving target. But for right now, it's actually restricted. It's been restricted to ID positions if that's gonna be used or not. And then we're also having to weigh this against getting patients enrolled into our treatment protocols such as remdesivir, which I think many institutions are probably participating in. So that's always the big question is how do you balance those things? And I don't think there's one single right answer, but at least in terms of the practical logistics of this, for us, it's gonna be restricted through ID so that the administration might be a little bit more uniform and then balanced also with enrollment into some of these clinical trials. So we have been using hydrochloroquine and instead of azithromycin, since we saw a lot of QT prolongation, we have been using doxycycline based on our ID recommendations. So again, I don't know if they're specific with azithromycin because their recommendation was to cover community acquired pneumonia and we saw a few QT prolongations, so then they changed it to doxycycline with hydrochloroquine. Ron Stevens again. Regarding remdesivir, Gilead, which is the manufacturer, has stopped honoring requests for individual compassionate use of remdesivir except for pregnant women and children less than 18 years of age and are encouraging enrollments in ongoing clinical trials in the United States. And in addition, there are some ongoing clinical trials in China. They do have a strict cutoff though. I mean, the GFR has to be more than 50 for them to be eligible. So what we've been trying to do is start them sooner rather than later because we're seeing a lot of AKI as it happens in these patients. So just something to keep in mind. I think as a reminder, there's no recommendations from the SECM guidelines regarding the use of hydrochloroquine in curable adults with COVID until we have more data. The other question is, since we know there's a phase two with hyperinflammation and cytokine storm, one of the questions is, what is your experience with IL-6 and other immunomodulators in these patients? Is there any experience? Dr. Stevens, no experience. Yeah, here in Texas, it's not part of any research or standard kind of impaired therapy for us. So as far as I know, it's not been used. Same here. Okay. There's also a question, which also in terms of therapy, what about the use of pulmonary vasodilators, nitric oxide or epiprostanol? That is Chris Howard again. Yeah, I think this is actually a really interesting question because I've seen, so starting with the SECM guidelines, they do recommend vasodilators if needed. They tend to, it looks like the language, they tend to shy away from using nitric oxide. But then they go to say that trials of inhaled vasodilators, which they're not specific about, would be okay. It's interesting because I feel like this is very institution-based. I've seen hospital protocols that mention using nitric oxide specifically and not using inhaled epiprostanol, for example. And then I've seen hospital protocols that actually say the exact opposite. And I think my impression is that a lot of this actually just comes from the local institution experience with one or the other. And they tend to favoring the one that they have the most experience with. If I had to generalize, I'd say a lot of the surgical anesthesia ICUs maybe are kind of favoring more nitric oxide and the medical ICUs are favoring more toward epiprostanol. But that's a very broad generalization. I think for the most part, we're pretty comfortable using epiprostanol. If we get into a refractory situation, as we're starting to paralyze and think about chrony in these patients, that's generally kind of the workflow that we've established for our hospital. That's kind of generally where it falls in terms of our utilization of these medications. Any other thoughts or comments about different treatments before we move on to a different topic? In terms of steroids, there's also mentioned that people have been seeing anecdotally more clotting on the CRT circuits. Has that been experienced by other panelists? We've been seeing that and we had a lot of discussions about this. I was going through what's happening across the country. That's something that has been noticed at other places as well. We tried putting citrate within our circuit, with the heparin within our circuit, still the circuit clotted off. We actually had to put in three dialysis catheter in one patient because the catheters were just clotting off. Then we went to a systemic anticoagulation with heparin, keeping the PTT around 50 to 70. That seems to have helped. This is something that we're seeing at a lot of other places as well. On social media, there was a lot of discussion about the same phenomena from a lot of institutions across the world. It looks like there's a hypercoagulable state that happens because of the inflammation. It's not in all patients, but it has been seen in at least a good percentage of patients who have ARDS and were critically ill with COVID. Excellent. Any experience with covalescent plasma? This is Chris Howard. None for us yet. I think that's available on a trial basis. This is one of those therapies that I'm actually very, very interested to see how it works and what kind of results we can get. Those are still just investigational phase. We have no experience in Milwaukee with convalescent sera. However, there is some limited data from China suggesting that the use of convalescent sera reduced viral load and was safe. There's also a question about proning. What are the recommendations for proning these patients and how early should we be instituting proning? Chris Howard, I'll step in and take the first shot at this one. I think we are using proning just as we would for standard refractory hypoxemia and moderate to severe ARDS management, which is once the standard ventilator optimization has occurred in terms of PEEP optimization, tidal volume optimization, starting to think about if it still becomes refractory, then we are instituting paralytics, starting to think about inhaled basal dilators. At the same time that we decide to prone, if those measures are not effective, then we're actually doing a concurrent ECMO consultation to at least get that part of the logistics taken care of if it gets to that point. So we're not treating it any different just because it's a coronavirus necessarily. But just to follow general recommendations for proning, I think the earlier that you get to these patients, the earlier you realize they need proning, the better off the outcomes are going to be. And so that management and that protocol practice for us has not really changed specifically in the coronavirus context. Dr. Howard, have you, you know, there's been a discussion and observation that many of these patients respond to proning, but once you turn them back, they desaturate really, really fast. Has that been your experience? So, you know, the number of total patients is pretty small, so it'd be difficult, well, I guess relatively speaking to a place like New York. So like other states, we're starting, we're going to, we're expecting kind of our surge here in early to mid-April. But generally speaking, I don't know if those characteristics are any different than other types of patients or any other types of viral pneumonia. It just means that they're simply not ready to remain in supine positions for long periods of time. So I don't think the guidance necessarily would change on that. And I think it's too early with the small numbers that have been done so far to characterize broadly what we're experiencing. There has also been a lot of discussion about extubations and readiness for extubations. Are you changing your regular parameters for these COVID patients or are you applying the same parameters for extubations for these patients? So again, just to follow up, I think that the protocols really for now can remain the same. I don't think there's any reason to change them dramatically. Anecdotally, I think we've all seen those reports of, well, even if patients are on low peak prior to extubation, they seem to have real problems with recruitment. And so I think you have to be extra aggressive about, you know, working on things like incentive spirometry and all the normal things we would do for airway clearance. But I don't think anything needs to be done specifically differently than just your standard extubation criteria. I've heard, you know, again, smaller comments about not doing cuff leak testing because of aerosolization concerns. So that might be the one small nuance that I've seen in terms of recommendations for extubation, maybe just adjusting those things more in relation to their aerosolization risk. So I'm going to add that, you know, out of, you know, again, the N for us has been about seven or eight, where what we have seen is that, you know, once you, as you had asked the question, so they love to be proned. Once you get them supine, be ready to go up on the PEEP and FIO2 because they do go down significantly after you make them supine for the initial, you know, 30 minutes or so. So be prepared to do that. That's what we've seen. Again, our N is not that high, but of these seven, eight patients that we have seen, this is something which we've observed. The other thing regarding, you know, extubation and weaning. So traditionally, you know, we have, and all of us kind of use PAO2 more than 60 to wean, you know, your PEEP, your FIO2. But what we have seen, and again, I'm talking about this because we just had a conference call before this where we went over the medical management of all these patients among all the intensivists. And, you know, so what they have, what we've seen is that, you know, if you use the same stringent criteria, they decompensate really fast. They're pretty fragile. And so we have been going a little slow with weaning in the sense we started aggressive, but then after seeing what we were seeing, we are now kind of weaning down based on their P by F ratios rather than just the PAO2. That's the only difference that we have done for just these patients. And again, that's because, you know, when we tried the usual stuff, we got burned. But again, this is an NF7, NF8. I don't know if that can be, you know, be said about every patient, but that's something that we have noticed. And these patients are very PEEP sensitive. They tolerate going down the FIO2 okay, but they do not tolerate going on down in the PEEP as much as they tolerate going down on the FIO2. These are the observations that we've seen for the patients that we have over the last week. Well, I understand there's, I mean, there's limited experience, but there's again, related questions since there has been reported about, you know, high and low compliance in these patients who are hypoxemic. Is there any observation or any comments about that? So what we have seen is their compliance is great. Again, as has been described from other places as well, their compliance is great. I mean, you know, and it's just that their oxygenation is just very, very precarious and fragile. So, you know, we have had no issues with the compliance. It's been, the compliance is just great so far. Two related questions. Any comments about tracheostomy? It seems that these patients remain intubated for a long period of time. And so there's a question about early versus, you know, late tracheostomy. And there's also some concerns about doing tracheostomy. Dr. Salinas, Dr. Stevens, there is some experience from Northern Italy. And in fact, a number of ENT surgeons have become infected doing, performing tracheostomies. And therefore, the, some of the ENT societies have issued guidelines and recommendations. In our organization, our ENT surgeons have decided that they will not perform elective tracheostomies in COVID patients or patients under investigation, because they believe that the risk to the healthcare worker outweighs any potential benefit to the patient because of the risk of aerosolization in infecting healthcare workers. So it, I'll just leave it at that. Okay. Do you know any details about the equipment that we're using to protect themselves? And is that an open or a percutaneous approach? I believe that the ENT surgeons that were infected in Italy were performing open tracheostomies. Okay. Thank you so much, Dr. Stevens. A related question from Matthew Meyer is, have people survived intubation and mechanical ventilation? And again, I acknowledge that the experience is limited. And he's referring to the trials that report survival range of zero to 3%. Yeah, this is Chris Howard in Texas. We have not, we have not experienced those dire numbers. Those sound, those sounds pretty unfortunate. But we actually have had several extubations, patients moving from ICU to floor. So we haven't seen the mortality numbers that that particular person has been seeing or seeing reported. There's also in reports, especially from China, and this is a real question about cardiac dysfunction and, you know, quote unquote, high incidence of cardiac injury in these patients and sudden decompensation. Have you, again, acknowledging the limited experience, have you seen this pattern of cardiac decompensation? This is Dr. Karamchandani. From our side, we haven't as yet. We did have one who went into a junctional arrhythmia, but then it, you know, it resolved with use of dopamine. And we haven't seen any troponin elevations or any signs of myocardial injury in these patients so far, again, with the limited time that we have and the limited patients that we have. We've seen some, but we've been able to medically manage through them, whether it's inotropes, whether it's antiarrhythmics. You know, the one interesting piece that I think, going back to the refractory hypoxemia and kind of the discussion about these patients are very hypoxemic, but yet have pretty good compliance. And I think there's been some discussions and even position papers, but about cardiology societies, about concern for pulmonary vasculature and microthrombi and the need for heparin. This is another thing that gets discussed about often. Some places are doing heparin for all their severe patients. Some are looking at D-dimer elevations as a marker to use in kind of empiric heparin. And then the question is, you know, if you were to randomize these people, how would that work out? So I think that's going to be an incredibly interesting research questions for the future. And also, do these microthrombi also involve the coronary arteries? And so are they just better medically managed rather than using kind of any percutaneous techniques? So super interesting questions that will definitely be one of the things that would change about our standard aortes management for these patients. But I think there's no way to be able to say from a randomized trial which way is better to go. I think that science and that information is going to have to evolve over time. But I do know a lot of places are using heparin empirically for these severely ill patients. And I think the description is not very specific. We know there's some cardiac injury, but we don't know if it's viral replication consistent with myocarditis. Are we talking about a stress cardiomyopathy kind of picture? So it's not very clear from the reporting. There's a question regarding ECMO in this patient. Is there anyone who would like to comment about how is ECMO being used in this patient? Or do you have a protocol for ECMO for these patients? Dr. Stevens here. We have not used ECMO in any COVID patients yet to my knowledge. We have gotten together and agreed upon some exclusionary criteria in light of the early Chinese data that suggests that most of the patients that went on ECMO died. So I think that the jury is out on that. We just don't have enough experience. I agree. The data still needs more time to be borne out. The one thing about our ECMO, we have in-house ECMO. The one thing we've slightly adjusted to our inclusion criteria is we're being a little bit more restrictive based on age. And I think some of that has to And I think some of that has to do with some of the early outcome data we've seen. And also the concern, honestly, just for the number of patients that would qualify, but yet we don't institution may not have enough ECMO circuits to support those patients. So for those reasons, we've been a little bit more restrictive on age so far, but otherwise standard criteria. I think we have the same thing as well as the criteria have been established. No patient has been on ECMO yet, but the criteria are a little more stringent, more specifically with the age, just like I was mentioned in our institution as well. Dr. Salinas, Dr. Stevens here again. Regarding D-dimer, that to my knowledge, the interest in D-dimer has come out of a Chinese paper, recent Chinese paper from the Lancet, which shows that there are some biomarkers that might be useful in separating survivors from non-survivors. D-dimer was one, ferritin is another. Both are much more elevated in the non-survivors than in the survivors. Over. There's a couple of questions regarding testing. So if someone would like to comment about the role of antibody testing and the PCR turnaround time and sensitivity and specificity of the test. So I can start here. We just had a huge discussion because one of our patients who tested twice as negative, but then showed pretty significant signs and symptoms suggestive, third time tested positive. So I think if you look at the SCCM surviving COVID guidelines, they also mentioned the same thing, that the false negatives with these tests are higher. And one way you could limit them is doing a tracheal aspirate, but again, you know, the swab needs to be corrected accurately and so on. So even then, with all that specificity is kind of on the lower, like the negative predictive value is kind of low. And you know, what has been recommended is that A, the swab needs to be corrected properly. B, if there's any confusion, I think a tracheal aspirate is better, although a BAL sample would be great. But since the risk of aerosolization is too high, it just doesn't make sense. From our institution, what we've been doing is that, you know, if we have a very high suspicion, and even though they are negative, we're still treating them as COVID positive, which is, again, this is a very difficult predicament. But we're also, the other thing which is mentioned is, you know, maybe you can get a CT scan and collaborate that. But again, putting everybody in the scanner is not feasible and logistically possible. So testing is an area of, it's kind of an area of concern. And, you know, we had our firsthand experience yesterday when that patient who was suspected and negative was on the floor, you know, without the adequate precautions, and then deteriorated, came down, and the next swab came back positive. Any other comments in terms of hospital protocols regarding, you know, isolation and de-isolation when patients come back negative? Dr. Stephens, I would just make a couple comments about organization of the hospital. So my advice to almost everyone I talk to is that the number one priority is to protect the health of the healthcare worker force. And number two is to prevent additional infections occurring within the clinic's emergency room hospitals. And so therefore, I believe that cohorting COVID patients and patients under investigation and separating them from non-COVID patients, starting at the triage point in the emergency room and continuing on through hospital discharge is very important. Because if we can prevent additional COVID infections, then we don't have to do ICU care on some of these patients. So I think that simple public health maneuvers such as cohorting and isolation and PPE are really, in the long run, going to be much more effective in limiting morbidity and mortality than the ventilator strategies that we use in the ICU. So I think that's one point. Regarding testing, I think there's a lot that we don't understand yet about testing and about the false negativity rate. One of my infectious disease colleagues pointed out to me that with any test that relies upon detecting viral particles, that the earlier the test is done, probably the higher the false negativity rate, which makes sense because it's a PCR test that actually detects a virus, not antibodies. I think that once we have tests that are available commercially that detect IgG and IgM antibodies, they may be more sensitive than the RT-PCR test that we have right now. So I think we're at very early days in this pandemic, and there's probably more than we don't know than we do know about how to best fight this enemy. Thank you. I would like to ask a question about how an interest I think that there's been a lot in the descriptions from the Chinese studies doing CT scans, and we have been trying to limit CT scans and chest x-rays to decrease the risk to the healthcare workers. And there's a lot of discussion about the role of point-of-care ultrasonography and also the risk of doing point-of-care ultrasonography. I was wondering what are you doing at your institution? Yes, Chris, I'll make a quick comment. I feel like when the outbreak was still very China-specific and centered in China, there was a lot of discussions about making sure everybody possible could get a CAT scan because the sensitivity was so good on that. And obviously, that has evolved as things have moved on because everybody realizes the infection risk. So, I think there's a lot of on that. And obviously, that has evolved as things have moved on because everybody realizes the infection risk. So, I feel like the guidance on CT is that only do it if you feel like it's absolutely going to change your management. But I think it's generally kind of deferred at this point, same with bronchoscopy, kind of the same attitude I feel like has evolved around that particular intervention. Chest x-ray obviously is kind of still the bread and butter of imaging. And then bedside ultrasound, I think unless you're seeing, I think a one-time exam up front. And then unless you see new changes, I don't know if there's a lot of benefit necessarily to putting yourself through the risk and the time that it takes to do that. That's just my personal opinion. But I haven't seen where it often changes a lot of management after that first exam. But if you have the luxury of doing that and you feel like you're well-protected, then I don't think anybody would say stop doing it. I just haven't seen it actually change management too often if it's going to be used on a repeat and frequent basis. I think it's being restricted if it's going to change the management and also the American Society of Echo recommendations is also stating that point of care should be first line but also should be restricted if it's felt that it's going to change the management of the patient. This will conclude our Q&A session. There are no other comments. Is there any other comments before we conclude this session? Dr. Stevens? Dr. Howard? No, sir. Thomas and Danny? No, thank you so much for the opportunity. Thank you so much for allowing us to discuss. Thank you, Dr. Salinas, for moderating this educational webinar. Thank you, Dr. Thomas and Danny, Dr. Howard, Dr. Stevens, and thank you to the audience for attending. Again, this webcast is being recorded. The recording will be available to registrants within 24 to 48 hours to access. Please go to covid19.sccm.org. There are more questions and answers calls scheduled on the dates listed here. All of them begin at 1 p.m. Central Time. Thank you all. That concludes our presentation today.

COVID-19 Q&A call

management of COVID-19 patients

glucocorticoids

ARDS

proning

hydroxychloroquine

azithromycin

convalescent plasma

anticoagulation

PCR tests