Good afternoon everyone, hello and welcome to the COVID-19 Q&A call. This is the second of six in series. My name is Rooz Behsharif, I'm a pulmonary critical care intensivist from Houston, Texas. I work at two different facilities and I have no conflict to disclose. Today we are going to have the second of the six series of the COVID-19 Q&A calls. The webcast is being recorded and the recording will be available to registrant within 24 to 48 hours. To access please go to covid19.sccm.org slash webcast. So a few housekeeping items before we go ahead and get started to submit your questions. You can use the box on the side and after the initial presentation type your question in the box located on your control panel. With that, now I would like to introduce our speakers for today's question and answer. Dr. Ashish Khanna is a staff intensivist and anesthesiologist, associate professor of anesthesiology and associate section head for research with the Department of Anesthesiology, section in critical care medicine at the Wake Forest University of Medicine in Winston-Salem, North Carolina. Our second speaker is Dr. Bullock who is an associate clinical professor of pharmacy practice and director of strategic operations at Auburn University Harrison School of Pharmacy, University of Alabama College of Community Health Science in Tuscaloosa, Alabama. And now we'll go right to the question from our attendees. The first question is going to Dr. Khanna. Dr. Khanna, one of the first questions that we have is what current PPEs are your frontline staff using, regular mask, N95, pappers, hair covers, what are your challenges with PPEs? Yes, thank you and thank you for this opportunity. I guess that's a very relevant question because we know for this viral syndrome at least at this time, prevention is better than cure. So based on that, PPEs are really significant to our practice. So what we have done is that we have tried to ensure and maximize the number of papper devices that are available to our bedside ICU nurses, to our respiratory therapists, to the doctors, nurse practitioners, everyone else who has to be in close contact with any known COVID patient or any persons under investigation or PUIs as we call them now. We do have N95 masks available, enough N95 masks available for now, but the general protocol is that if as a intensivist, I have to go in and do significant procedural time with these patients, then I will wear my papper device in a sort of a anti-room where we do our donning of the gowns, gloves, papper device, go into the patient's room, do all your procedures all in one go. What I mean by that is that try and minimize the situation where you intubate a patient now and then come back six hours later to do a central line. You probably proactively, if you are intubating the patient, go ahead, put a central line and go put an A-line in so you minimize your time in and out coming out of that room. Come out of the room, take your gown gloves off first, clean up everything, then take your papper off, clean it. We are in a situation, obviously we don't have a designated papper device for every single provider, so we are still sharing them around, which means that we will have to, we do religious and vigorous cleaning of the device itself once we are out of the room. There are other people who prefer using just N95 masks with adequate eye cover and hair cover. Again, some of it is personal preference, but again, we have enough papper devices and for now, that seems to be the easiest and best way for personal protective equipment. Well, thank you very much for that explanation. I think our second question is for Dr. Balogh. What are the most promising therapies for COVID-19 that you guys are using and what is the new information in the field? Alright, this is a little bit of a loaded question because I feel like the information on therapeutic seems to change on the hour, at least definitely by the day. Right now, the World Health Organization has about 80 different potential therapeutic candidates. We don't have them all in the United States, but remdesivir seems to be the best for, at least from what we're hearing, I'm sorry, I think I'm getting a little scratchy, seems to be the best for severe cases. A lot of encouraging information coming from case reports and things that we've seen in other studies. There's been a lot of discussion around hydroxychloroquine and whether or not it's going to be used. We have newer data that has recently come out last week based more on clinical outcomes. The early data was more on revolving around just viral clearance, but the newer clinical data both from France and from China indicates that it actually may be a good option in patients who are sick enough to be hospitalized, but maybe haven't gotten so sick that they need to be in the ICU or be on the ventilator. One drug that we're still sort of looking at it about whether or not it will be a contender is going to be lopinavir, ritonavir, which most of us have used in some form in an HIV patient over the last several decades. There was a study, many of you probably saw it, that was published in New England that sort of, I think, dashed a lot of people's hopes. But when we go back and we look at it, it was used as monotherapy and it didn't seem to be effective. But when used in combination with other antivirals or with interferon, it does seem to be working as a potential option. And again, and particularly in patients who are caught early. Some of the other things that are being discussed, but we really don't have a lot of data on, include IL-6 inhibitors. There's some new trials that are just rolled out in the last week or two in the United States. And so we can hopefully expect some data, even preliminary in the next few months, about whether they're helpful in repairing some of the tissue damage. Nitric oxide is also being looked at in your patients who are being ventilated as a way to help improve blood flow and reduce some of the damage to the tissues. And then steroids, although not your traditional antiviral agent, is one that I think a lot of people are paying particularly close attention to because we've used them for ARDS for decades and it's our standard of treatment. But we have that data from SARS and MERS that indicated that they were actually harmful. But anecdotal report in some early cases that have been published, at least thus far, seem to suggest that patients are sicker and are on the ventilator, they are responding to methylprednisolone. So right now, that's the information that we have data on. There's a lot of data on antivirals that we don't have yet in the United States, drugs traditionally for influenza. Many of them come from Asia or Russia. They look very promising, but we don't have them here. So I don't know if the companies that make those are planning on submitting for FDA approval or not. But that's essentially where we are at this time. Thank you very much. It was very helpful. Dr. Kano, the next question is for you, and this is in regards to asymptomatic patients. In regards to COVID transmission from asymptomatic patients, the question was, should all providers and nursing staff who are taking care of those patients in close proximity wear N95 masks in hospitals? That's a great question, and it's a great question because it's sort of dependent on what hospital environment you're working in, what are your regional and local resources. Obviously, if you're running tight on N95 masks, then this sort of becomes a slightly lower priority compared to the actual priority that you have. It's a slightly lower priority compared to the actual positives or the patients who are under investigation. But if there is enough N95 masks available, then certainly I don't see any harm wearing them around asymptomatic carriers. Although the second part to that is that it's essentially very difficult to identify an asymptomatic carrier, which would then mean that, you know, do you just wear your N95 mask in the hospital all the time? Again, and that is sort of institution specific, but at my institution, we at least have gone to wearing a regular surgical mask anytime we are inside the hospital premises. So once you're inside a hospital premises, whether you're on the ICU or the floor or walking through anywhere else, there is a fragile chance of exposure to an asymptomatic carrier. So anyone who's inside the hospital is wearing a regular surgical mask all the time. And then obviously, if you're in contact with a PUI, then an option to switch to an N95. So that for now is the best sort of protocol I can provide since no two hospitals or institutions are the same in terms of the availability of resources. Thank you very much. And I think that's a very kind of a common scenario in most of our hospitals with our colleagues. I'm sure our audiences are pretty much experiencing the challenges that you have. And that's what seems to be one of the main problems. Dr. Bolaghar, next question is for you and about the impact of the ACE inhibitors on patients who have COVID. Thank you. That's actually a really interesting question. I guess let me back up and explain where the issue with ACE inhibitors first arose. When SARS and MERS first emerged, especially with SARS in the early 2000s, they did some laboratory research when they realized that the virus itself gained entry into the host cell using the ACE2 enzyme, which we know is upregulated in patients who are taking ACE inhibitors or ARBs. And so there was a lot of concern. Could this make it easier for the virus to gain entry into the cells? But on the other hand, when we look at the pharmacology of those drugs, it would make sense that no, it might actually help block entry into it. And they did some laboratory research in vitro data that suggested that the use of these agents might be helpful, but it stopped there. There was never any clinical data in MERS or ARBs that suggested one way or the other. And so when COVID-19 came out, this debate emerged. And I think that there were a lot of people who argued one way or the other. There were also those who were looking at some of this in vitro data saying that maybe the ACE inhibitors and ARBs will even have a protective effect with the lungs. We didn't have any data until literally Wednesday morning. There was a study that came out. It was an observational study from China. It looked at patients who had tested positive for COVID-19 in mid-January to mid-February. And they teased out patients in that group that had hypertension. And they looked at 42 patients, and just under half of them were on ACE inhibitors or ARBs. And then they looked at patients who were on other antihypertensions, which for that group included beta blockers, calcium channel blockers, and diuretics. And they looked at how they did, and they didn't provide a lot of outcomes. I mean, it's sort of early. We don't have the statistics that we would normally like to see. But overall, patients who got ACE inhibitors and ARBs did significantly better than those who were on other antihypertensives. None of them ended up needing to go to the ICU. They cleared the virus faster. They had several other secondary clinical outcomes that were much better than their patients who were their counterparts who were taking other antihypertensive. So it's an early study. It's a very small sample size. We do need larger, more robust analysis. And I think at this point, it's all going to be retrospective. But we're getting to a point where I think that that data is going to be available soon. But I think at least now we have something that we can feel a little bit better about leaving our patients on ACE inhibitors and ARBs and not taking them off. There are two clinical studies that are going on in Minnesota right now where they're actually starting people on Losartan. One is going to be an inpatient, and one is going to be an outpatient. Those are set to run for the next 12 months. And so not only by the time we're here next year will we know exactly how protective these drugs are in patients who are already on them, we'll know if maybe they'll even be beneficial in starting in people who've never taken them. So that's where we are right now. It's not a lot of information. But I think from where we were just two months ago, it's a tremendous amount of relief for those of us who care for patients who have hypertension, especially since they're one of the most vulnerable groups. Thank you very much. That was really thorough. And thank you, especially with going a little bit in the background of the medication. It's certainly one of those hot topics to talk about in regards to care for patients with COVID-19. Dr. Khanna, the next question that we have for you is in regards to use of the non-invasive positive pressure ventilation. And the question is essentially, are people focusing on early intubation and avoiding BiPAP due to possibility of BiPAP causing more sort of aerosolized spread of the virus? The simple answer to that question is, yes, avoid non-invasive positive pressure ventilation because that will increase chances of dissemination or spread of the virus particle. The other side to that answer is, well, what do we do for all of those patients who sort of were utilizing non-invasive ventilation as a bridge to save them from mechanical ventilation, intubation and mechanical ventilation? So the short answer to that is that it's a tricky call. You certainly don't want to intubate a lot of patients who would otherwise, you know, just stay at low O2 stats for a little bit and turn around and do well. On the other hand, you don't want to wait till it's too late. Something that has been tried is self-proning awake patients. So essentially you ask awake COVID patients who are on significant amount of oxygen and are not able to keep up on their oxygen saturation to essentially turn themselves prone and stay like that for two to four hours at a stretch or as much as they can tolerate. And from all the evidence that's coming through all over the country and from personal experience that, I mean, I have done this on my patients. I've seen that oxygenation goes up pretty significantly. And does it eventually save them intubation and mechanical ventilation? Well, we'll have to analyze that data and see if it does or does not. At least it buys time for us to see whether there is going to be an overall turnaround and recovery of organ systems. There are people in Europe who are advocating for earlier intubation in these patients in general. However, again, there is no real data that has compared early intubation versus standard of care or early intubation versus self-proning. A lot of questions that remain to be answered. Again, early intubation would not necessarily be the best answer. However, if early intubation is done, then be very careful with lung injury, which would be secondary to volute trauma and barotrauma. So just to circle back to your original question, no, I don't recommend non-invasive positive pressure ventilation for now. I would encourage things like self-proning once you are beyond 8 to 10 liters of oxygen and see if self-proning buys you time in terms of oxygenation. And then if that doesn't work, then certainly intubation is the way to go. Thank you very much. And yes, there is certainly a lot of recommendation against the using of BiPAP and that possibly could have some effect. But, you know, one of the good things that we are experiencing, as you mentioned, use of proning on awake patients. that is probably one of the good things that you're going to learn from this crisis. Dr. Bullock, I'm going to proceed to the next question for you, which is about current prophylaxis against COVID-19. Do you have any updates on that for us? Sure, and I think a lot of this came from when some of the early options for treatment came out. A lot of people recognized hydroxychloroquine as a drug we had in the United States and thought, well, I'll go ahead and try to get some in case, you know, I come down with it. And then a lot of people started thinking, well, wait, what do we do if we get, we are exposed to it much in the same way that we think if we get exposed to the flu? Unfortunately, I just, I guess this short summary is, is we don't have any data on any drug being good for prophylaxis for it. The most we have at this time is an observational snippet from a study. It wasn't even data that suggested that patients and their evaluation who had been on hydroxychloroquine for lupus never came down with the virus, but there's, that was just one sentence in a long study. There are two studies right now going on in the United States looking at hydroxychloroquine for post-exposure prophylaxis. The one at Columbia looks like they're looking just household contacts. Another one is looking at not only household contacts, but health care providers, so that would be us. And they are looking at that one more of a nationwide type of thing. Canada is doing a third study, but they're looking at lopinavir, ritonavir. They're also going to be looking at health care providers. But these studies just got kicked off, and it's going to be a while before we even know, because we've got to get through this current crisis to see, you know, if they actually were effective at preventing us from catching the virus, and that it wasn't just something else like herd immunity. So we don't have anything yet at this point, unfortunately. Thank you very much, and I hope something comes out of the pipeline sooner. Dr. Khanna, I have the next question for you, which is, what is the relationship of ACE inhibitors with the basically disease progression? So I guess part of this question has already been answered before. Clearly, there is, you know, the association of ACE inhibitors themselves and the association of ARBs is something that is obviously really exciting, and we have to do a lot more work in this area. To my best knowledge, there is minimal data right now to clearly say that, yes, if you are on an ACE inhibitor, you will have a worse outcome. In fact, the American College of Cardiology and the European Society of Cardiology do not recommend taking people or taking patients off ACE inhibitors even when they test positive. The honest practical implication of that is that, you know, if your patient has tested positive and is now in, you know, a hemodynamically unstable state and on pressers, then likely he or she will not be on ACE inhibitors at the back end of that. So, you know, I discuss practices where people would stop ACE inhibitors on a hemodynamically stable positive patient because clearly, you know, there is no real data to show that one way or the other. On the other hand, there is, you know, Marilyn brought up some really interesting points, and I'd like to, you know, talk a little bit about the other side of the coin. The other side of the coin is actually using exogenous angiotensin 2. There is also the thought that while ACE inhibitors and ARBs in themselves may or may not be beneficial, exogenous angiotensin 2 has been shown in animal models to downregulate ACE2 receptors, and we don't have any human data, but I have colleagues in Italy and the United Kingdom who have been using the drug as a mechanism to downregulate ACE2 receptors and as a mechanism to compete with the virus particle with binding on the ACE2 enzyme, whether that, again, no clinical trial and to substantiate that claim, but as you can see, there is so much more that we will know based on all of what we are doing right now, maybe another six months or a year. I'm going to proceed to the next question for Dr. Balogh. Do you have any update on treatment options, open and ongoing clinical trials? I think you did cover some of these on your previous answer, but I'll leave it up to you if you have any more to add for potential treatment options. Sure. Right now, the drug, I think a lot of us are really wanting to see the data for our most severe patients is remdesivir. Right now, there are three clinical trials underway in the United States. You can still technically get the drug through compassionate use, but it's become a little bit more difficult. NIH is conducting an adaptive trial at 39 sites across the United States. Right now, they're randomizing people to placebo or remdesivir. If and when they find remdesivir is superior, then remdesivir will become the control and they'll start to evaluate other potential options against it. So, we'll get a lot of head-to-head data from that. Now, Gilead is doing some of their own phase two clinical trials across the United States. One trial is in severe patients and one is in moderate. Neither one of those are enrolling patients who are already on the ventilator at the time of enrollment, but getting put on the ventilator is one of their outcomes for at least one of their studies. Then, the World Health Organization is doing a solidarity trial, which initially was just going to look at head-to-head standard of care, hydroxychloroquine and remdesivir, but they have since added interferon and lopinavir-ritonavir as potential treatment arms. So, I think we'll get a lot of good, not only do these drugs work, but how well do they work in relation to each other and under what circumstances from that. There are several more trials out there looking at hydroxychloroquine and what settings that are going on. There seems to be less of that in the United States. In other countries, there's a big trial in Detroit. There are several going on in New York, but a lot of that data is coming from other countries. And then, lopinavir-ritonavir seems to be one that a lot of people are looking at, more so in combination with other medications and looking to see will that be part of our cocktail. Other things that are maybe under the radar, I already mentioned the two studies with Losartan that are underway. UAB has just initiated a study on nitric oxide for their patients who are in the ICUs. There are several that are looking at different vaccines. So, there's two vaccines in clinical trials in the United States right now. There's two others in clinical trials in other countries. And then, we talked about some of the prophylaxis agents. Other than that, the only other thing I want to mention is that othetimivir or Tamiflu, which many of us are very familiar with during flu season, is also being looked at in some clinical trials outside of the United States, not as monotherapy per se, but as part of a regimen or a cocktail and thinking that it might have some potential benefit, particularly as patients are co-infected with both COVID-19 and the influenza. So, we've got a lot of data. Some of the biggest trials are set to end this fall, so late fall, early winter. I don't know how quickly they're going to be able to analyze that data and get it out, but hopefully before the next season rolls through, we should have a lot more concrete idea of what we need to do to treat these patients. Well, that's awesome. Thank you. Thank you very much. I have, again, frankly, in that regard, one of the hospitals that I work at, I was preparing a draft for management of the COVID patients, which brings me to the next question, is following the surviving sepsis campaign guideline that was published by Society of Critical Care Medicine in mid-March, do you have any update to that? Because I think there were some stuff that back then we didn't have the data of when the guidelines came out, if you can fill us in. Right. So, there haven't been a lot of updates to it. The guidelines are set to be updated almost on a rolling basis as some of this data comes in. Some of the things, at least looking at the data that we are reporting, prone therapy seems to still be one of the most effective things, at least for patients who do end up on the ventilator. And so, with that, using paralytics to help facilitate that seems to be really helpful with our patients. Many of these patients are finding, especially the more severe ones, do have a secondary bacterial infection. So, at least empirically starting antibiotics also seems to be helpful. So, I don't know that those recommendations will change too much. The only thing that I think we have a lot more data on is hydroxychloroquine, which we've talked about. We don't have data on the anti-IL-6 agents, but those are underway. So, we should have those with the next coming months. And then steroids, we still don't know what to do with steroids. The World Health Organization and Surviving Sepsis sort of agree that with mild disease, we probably don't need them. But as patients progress into this ARDS, using low-dose short courses are probably more helpful than harmful. But at this point, we haven't had a ton more information that has come out other than what we've already talked about. Well, thank you very much. Yes, definitely, there are a lot of different trials and studies going out there. There are multiple questions, and actually on the slide, I see some of our audiences have similar questions on sedation and paralytics used in patients with COVID, whether you feel that that could be any difference with the ARDS patient, if you can fill us about your practice and your thoughts on this subject. Dr. Bode, do you have any comments on that and the use of paralytics? I don't know if I have any additional thoughts on paralytics and what's already been said. At our facility, we've been fortunate that we have still been able to use some of our more traditional sedatives. But within our COVID-19 ICU, we are trying to look at alternative methods, and I think many people around the country are sensitive. If we can get away with intermittent boluses of hydromorphone rather than continuous infusions just to reduce nurse exposure time, we're trying to do those. Some of us are dealing with shortages around the country, and so the intermittent approach seems to be helping both protect our workforce on exposure as well as protecting our available resources. One last question here that I think it's a more case-by-case sort of a scenario, which is how should COVID-19 affect our treatment of other patients in the community or hospital? I think all of us as a healthcare provider, we try to always maintain the fairness and essentially treat all of our patients the same regardless of background or anything else, but certainly COVID-19 as a pandemic is impacting our day-to-day life and sure our practice. Do you want to share some of your thoughts with us and our audiences, please? Sure. I think we have to, from a humanity perspective, remember that we don't just have COVID-19 patients in the hospital, and we have people who are there for the reasons that they've always gone there for, and they need the same attention that we would give them otherwise with reasonable protections, but unfortunately, I think some of the things that we may be seeing is that there are, on the bright side, we're probably getting better at maybe avoiding unnecessary tests and procedures and consultations. On the downfall is I think sometimes patients may be coming in and being tested for COVID-19 even in the absence of symptoms, and that might be delaying care, being unfortunately misaligning people's thought process in terms of what they need and when they can be seen. It also seems to be delaying our ability to transfer people out of the hospital or even get them into rehabilitation centers and nursing homes when they need to be, need to. So, I think the biggest thing just to remember is we, even though we're in a pandemic and we're aware that a lot of people are asymptomatic, or they may not have your traditional symptoms, we can't lose clinical judgment. We have to look at the person holistically as a whole. We have to take each person individually, and we have to treat them for what they come into the hospital with. So, I mean, if they become a patient who comes in with an intra-abdominal infection, you need to make sure that you evaluate their intra-abdominal infection. You need to make sure that we're treating them with the right antibiotics. We're looking at everything holistically. Thankfully, I think a lot of places, maybe outside of hotspots, are actually seeing a decline in some of their hospitalizations overall just because we don't have the elective procedures. It seems like some people who usually would go to the hospital if they felt a little sick or maybe not going to the emergency room as often as they would. So, we aren't as overwhelmed in all areas as we might be, but I think the biggest thing is just to remember that not everybody has COVID-19, and we have to maintain our humanity and our approach and our clinical judgment when we look at those patients. Absolutely, and thank you very much for touching that very essential and basic things that all of us as healthcare providers believe in, and I think in the two hospitals that I work at, and understandably, we work with our colleagues, and our colleagues are part of our community that we serve. Certainly, there are a lot of anxiety going on, and people have, you know, conditions. Even healthcare providers have comorbidities that essentially are concerned for that, but I think that definitely we are seeing a paradigm shift in healthcare industry in general, and decreasing the number of the elective surgeries and procedures can be really happening, something that basically in the community level we see more often, but I think I agree with all of your points. I think one of the questions about, again, sedation and paralytics, that what other what other good options are available when propofol and fentanyl are no longer available in ICU setting, especially considering the drug shortage, how do you decide which patient to receive the sedation and not during a drug shortage during surge time of the care, and I think this is mostly going through the concern for shortage of the medication, and especially when it comes to sedatives and paralytics. Do you have any update on the resources and what medications are getting close to national shortage, Dr. Report? I know I've seen a shortage at least last week. I don't know if it's been resolved with potentially fentanyl. I think the strategy my hospital is using in several other facilities that I'm aware of is, like I said, using those intermittent boluses, particularly with hydromorphone, so trying to dose it every, just depending on the patient, every two to six hours and what their needs are, as well as maybe patients who aren't in COVID units, but who are in other ICUs for other reasons, trying to, you know, allocate different, you know, morphine or other types of potential sedatives or moving away from continuous infusions when we can, and try to restrict those for patients who maybe need it because they are paralyzed or something along those lines has been very, very effective. We haven't, we've been fortunate, we haven't had a shortage of propofol, and so we are still able to utilize that. We have all of our pumps outside of the COVID-19 rooms so that nurses can titrate them without having to go into the rooms. Dr. Khanna? Can you guys? The question was in terms of the sedation and analgesics and what strategies you guys are using, especially with the concerns for national shortage for specific analgesics and sedatives. What are the main challenges that you guys have and what strategies we would suggest to listening. I'll take that back one step I know we were talking about sedation and paralytics. The reason that we're sort of short on supplies all over the country is that personal observation and other clinical observation coming in all over the world is that these patients tend to use up a lot of sedatives and still may not be appropriately sedated. I've had a few cases of patients self-extubating themselves on even on high doses of propofol for example for sedation and mechanical ventilation and which has led to a lot of practitioners trying to add two or three agents and continuous infusions to keep these patients sedated. We all know that unwanted extubations in COVID-19 mechanically ventilated patients in the ICU can be disastrous on various fronts not just you know patient well-being it's for the you know the person who's going to have to go in and re-intubate them their exposures as well. So what a lot of institutions have started doing is that use you know high-dose propofol combined with you know fentanyl drip or you know with or without using some some other agent even a benzodiazepine to keep them calm and that is one reason why we've started running out of of some of these agents. At my institution we've started switching to dilaudid drips for example instead of the usual fentanyl infusions if if needed. I personally do keep them deeply sedated because I want to be sure that you know with yes within limits of still trying to wake them up and do spontaneous breathing trials we're still in a in a position where we avoid inadvertent self-extubations because that I feel can be really disastrous for for these patients. I know that there was a question about paralyzing and the use of muscle relaxants and in the ARDS population and just to address that because I missed that I really don't believe that there is any data that has shown the advantages of you know early paralysis for example in management of ARDS in these patients I would still stick to the general guiding principles of the you know ARDSnet protocol for low lung protective ventilation and appropriate use of sedation and if you know beyond using sedation and and all of that we've exhausted all our resources then yes paralysis at a certain point but certainly not you know doing anything very different from from the ARDSnet protocols or the recent work that that came out of the you know the PETL network and so on and so forth. Well Dr. Khanna, thank you very much. I think I'm going to cover a couple of the questions that were mentioned here. What is your, what are your thoughts about the best way to flatten the curve? We hear about it a lot and how do you feel about the best you know good strategies to enforce social distancing when rounding in ICU? I think obviously we still would like to do our care for all of patients and without sort of hesitation but if you can share your thoughts and your experience from different strategies that you guys have used I would appreciate it. Right, so it's it's an important question because while we advocate religiously for social distancing and we have already started seeing the benefits of social distancing in terms of the slight flattening of curve of the curve that's happening all all over the country, the ICU environment is tricky because we tend to cluster in groups and and function better as a team in general. Some changes that I have made in my personal practice is that you know previously we used to round with our nutrition person, our occupational therapist, our clinical pharmacist and the entire team used to round together including you know the some of the nurse practitioners, students, medical students, so on and so forth but we have really scaled that down so now while I round I try and do individual rounds so just me and the specific ICU nurse taking care of that patient and and then limit I'm sorry and then and then and then come back to to talk to the rest of the team about every patient sort of separately. I know that's not probably the best thing or that's not part of sort of a collaborative effort but I still feel we can at least limit exposure versus you know eight or nine people standing and talking about a patient standing around in close quarters so I think it's still doable. I go back and talk to my nutrition person separately, go through the entire list, I go back and talk to the physical therapist separate separately and go through the entire list, I go back and talk to you know the other ancillary providers, respiratory therapists for example and go through the entire list again but when I'm rounding I just round with the specific ICU nurse on on the single patient so that's an example of appropriate you know de-escalation of the clustering in the ICU and still being able to provide appropriate ICU care. Thank you very much yes and that's sort of what I personally experience in both institutions that work are multidisciplinary round on MDR population have gone down we have limited number of people and one specific thing is one of the institutions that I work with did the bedside multidisciplinary round which patients were really giving us very good feedback and they were happy because they felt more included in the process of care delivery however now with everything going on people are not having visitors and to minimize the chance of a spread of the disease to our colleagues and the really brave healthcare providers who are who are really putting their life in danger to take it as care that they can, they're doing the same process. There's a question about pathophysiology of the VQ mismatch in the COVID lung. Do you have any education for us on that? The question is what is the pathophysiology of the VQ mismatch in the COVID lung and there is also a question about how are you cleaning the corded trays. I think we can probably focus on the latter one because that's a more common problem that we have the code blue trays and the code cards for the ACLS resuscitation. Now are you guys having a specific process for sterilization for the code trays? We are leaving our code cards outside of the room and the pharmacist who normally would go into the room with a code card is staying outside of the room when we've implemented sort of like a chain to get the appropriate medications in there but they are still responding and going and so it actually probably is even a little bit more organized than a normal code would be. We also have a second member of the team will bring a backup bag either intubation bag or a code bag that has supplemental information so if anything actually has to go into the room it's going to be that bag rather than the code card just to sort of minimize exposure for everybody involved and so really trying to keep the minimal number of people that need to be in that room in the room and that seems to be working. It seems to be flowing pretty well where we are. Yeah but that's an excellent thought and there's another question about the recycling of the personal protective devices like the masks and face sheets. Do you guys have any thoughts on recycling PPEs? Yeah so again that would depend on specific institutional resources. For now we are not practicing recycling of personal protective equipment because we are still in a situation where we have enough. In general we tend to especially with N95s we tend to limit you know a N95 mask to a single provider for at least the entire course of a single shift rather than you know throw it away every time you use it but and face shields yes I mean if we use face shields and those can be wiped down all the time just using chlorhexidine wipes and very simply reused. That's the exact same thing we're doing with the paper devices. They have face shield as well you clean them out really nicely and then you essentially reuse it. The N95 masks obviously in institutions where they're really tight on them I'm sure they'd have to come up with certain more innovative mechanisms or trying to conserve them. For now you know things like you know excessive recycling of N95 masks might not be the best way to go about it because in the end it does tend to lose its ability to actually keep the virus particles out if you end up you know sort of reusing it again and again and again over a period of time. Thank you very much and there is I'm going to go to another the last question from our audience for both of you guys and that's about anticoagulation prophylaxis on patients with COVID and for the patients with high D-dimer level whether you comment the different method for the dose of anticoagulation. That's a that's a very good question. I feel like it's a topic that has emerged this week in strong discussion. What we've been hearing from data coming out of our patients in America that we maybe didn't hear earlier on is how many of these patients do have micro emboli. I haven't heard and maybe Dr. Khanna has of you know full-blown or DVTs although that certainly is starting to be talked about but it does seem prudent that all of these patients need to have some form of medicinal DVT prophylaxis. There is some debate I just saw it this morning I haven't seen any clinical data on it that with patients with very high D-dimers that they're starting to provide full anticoagulation with heparin drips or full dose of anoxaparin. I don't know that I can speak to the utility of that because it's all been anecdotal and we really don't have the data on whether that's helpful or harmful but I do think just like we would in most critical patients we need to ensure that these patients are protected with at least prophylactic doses. We're not at this time using things like bivalorirudin or anything like that. We need more data before we jump full into that. It's my personal opinion. And I totally agree. I totally agree with all of that. I've had one or two patients at least one patient who developed a full-blown DVT a new DVT during the course of illness. Fortunately it did not result in a PE and you know you sometimes wonder would it have been different if we had fully anticoagulated from the get-go. I don't know the answer to that. Clearly full anticoagulation is not without its own risks. So for now I haven't changed my practice at all. Still waiting on better data to come in to support full anticoagulation though I will say that I'm very careful now specifically in patients who are as it is in a hypercoagulable state suppose someone has a malignancy or someone's you know pregnant or something then be extra cautious and really watch that D-dimer on a daily basis and obviously your clinical exam as well. Thank you both for the very thorough explanation for this issue. There's another question that was interesting to me. I'm sure a lot of us are hearing more about telemedicine. Is anyone using iPads for providers to see patients or assisting rounds so the rest of the team can just see the patient through the iPad and not not to have to come in the room and having the risk of exposure? So we actually started that several weeks ago because we have I'm on a teaching service and we have some older attendings that are in that high risk category you know if they were to get COVID-19 they would be more they would be at higher risk for severe disease and so to protect them as a provider we actually had the the resident take you know the phone into the room and connect using the video conferencing category and the attending was able to conduct the the exam virtually. Now the attending was just outside the room so it's like not like he was very far away. That worked very very well and I think was something that the patients appreciated being able to see the physician and they understood why you know they couldn't necessarily the physician couldn't come in. Now it wasn't with every patient it was just the ones where COVID-19 tests were either positive or that they were pending but we've used it and it's gone very well. Yeah same experience here although I haven't used the iPad but I will say that first of all patients are very cognizant of the fact that you know this is a highly contagious disease and you know they've been they've been at least my experience has been that they understand that we're trying to limit the number of providers coming in close contact with them. We in general have rooms that are you know just sliding glass doors where you can actually see a patient all the time. We encourage we we write things on the glass doors for them to see from the inside so we they can understand what we're trying to do and then use as much technology as possible. There will be obviously that you know you will have to do a certain basic exam. I for now have not had the opportunity to try the face timing sort of mechanism but I guess it's a very useful idea in general. Thank you very much Dr. Conlop. There's another question about the vent management. Do you have any recommended ventilatory strategy and vent setting management recommendation for our audience? So from my perspective I know that there is a lot of talk about the you know the high compliance compliance and low compliance phenotypes in these patients. Actually most of what I have seen have been relatively high compliance. I will say that I'm very religious about low tidal volume ventilation in these patients as long as I can prevent obvious hypoxemia. I will titrate down by my PEEP and FiO2 to an appropriate place. For now again you know there is a lot of running speculation on the fact that these are not typical ARDS lungs and I sort of agree with that because at least the patients I have seen have not presented with really stiff lungs. They have presented with lungs that are difficult to oxygenate but not necessarily stiff lungs. So keeping that in mind I try and adopt the minimalist approach where you know sort of a less is more approach where you know try and do minimal harm with the mechanical ventilator and still have the ability to oxygenate your patient. While we're still trying to understand you know how like you just said in your last question how does hypoxemia set up in these patients. I'm guessing it's a combination of a shunt physiology secondary to hypoxic pulmonary vasoconstriction and it's also a fact that they do have very significant capillary leak and it does help to keep these lungs dry if anything and that those are you know you know some folks have tried inhaled nitric oxide just to their benefit. I don't have a strong experience with that but I definitely try and keep these lungs really dry including aggressively using diuretics while they're on the mechanical ventilator. Absolutely and that's something that seems to be more compatible with my personal experience taking care of the COVID positive patient with ARDS that their way of having a presentation with ARDS is a more kind of a spectrum some in a more less compliant lung and some with more compliant lung but they definitely have more pulmonary vasculature involvement. So many many interesting points were touched today and thank you very much thank you both very much for useful information. I would like to thank our audience for participating and again I think as it was mentioned earlier the this recording is going to be available on covid19.sccm.org webcast within the next 24-48 hours for those who have registered for the QA session and that will conclude our presentation today. Thank you all very much. Thank you. Thank you.

COVID-19

PPE

therapies

clinical trials

sedation

prophylaxis

DVT prophylaxis

social distancing

telemedicine tools

recycling PPE