SCCM Resource Library-COVID-19 Ventilator Management

Video Transcription

perspective of COVID-19 ventilator management. This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention.  The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services. The contents of this resource do not necessarily  represent the policy of CDC or HHS and should not be considered an endorsement by the federal government. My name is Danielle Davison and I am an Associate Professor  of Critical Care Medicine and Anesthesiology as well as the Division Chief of the ICU at the George Washington University Hospital and Associate Fellowship Program Director  in Washington, D.C. I've been in academic and clinical practice for 14 years and prior to becoming the Division Chief of the ICU, I was previously the Fellowship Program Director  and Clinical Clerkship Director for the medical students in the ICU. My special interests of research in the ICU include hemodynamic monitoring, acute kidney injury,  medical education, and palliative care medicine within the ICU. I will be moderating today's webcast. This webcast is being recorded.  The recording will be available to the registrants within 24 to 48 hours. To access, please go to covid19.sccm.org  forward slash webcast forward slash.  Thank you 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.  One disclaimer here, this presentation is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter  that may be helpful to others. The views and opinions expressed herein are those of the presenters and do not necessarily reflect the opinions or views of SCCM.  SCCM does not recommend or endorse any specific test, physician, product, procedure, opinion, or other information that may be mentioned.  I'd like to introduce your speakers for today. Andrea Sikora is a clinical associate professor at the University of Georgia College of Pharmacy with a practice site in critical care  at Augusta University Medical Center in Augusta, Georgia. After receiving her doctor of pharmacy degree from the University of Georgia College of Pharmacy,  she went on to complete two years of residency training. She completed an ASHP accredited PGY1 pharmacy residency at UNC Medical Center and continued at UNC  for a PGY2 critical care residency. In 2021, she completed the Georgia Clinical and Translational Science Alliance KL2 Scholars Program  and earned her master's of science in clinical research. Dr. Natalie Yip is the vice chair of clinical operations at the Department of Medicine,  associate director of medical intensive care units and the medical critical care service and associate professor of medicine at Columbia University Irving Medical Center  in New York, New York. With a particular interest in the role of information technology in improving patient care, Dr. Yip serves as the critical care IT liaison  for the hospital and is very involved in multiple hospital committees and initiatives with a global focus on improving quality of care in the ICUs and beyond.  Additionally, Dr. Yip continues to devote much time on education with a passion for invasive mechanical ventilation. She is also engaged in research related  to healthcare implementation and delivery. Karsten Roberts is a registered respiratory therapist and adult clinical care specialist, as well as an education clinical specialist  at the hospital of the University of Pennsylvania in Philadelphia, Pennsylvania. He earned his respiratory therapy degrees from Boise State University  and master's in respiratory care leadership from Northeastern University. And now we will get right to the questions from our attendees.  Okay, Andrea, if I can ask you first this question here, how would you describe sort of a successful interdisciplinary approach to ventilator management in COVID-19?  I think you're on mute there, Andrea.  Forgive me, that's a wonderful question. When I think about interprofessional collaboration and a multiprofessional team as a whole, what I'm really thinking about is the dialogue  that's happening at the patient bedside. And that's truly my favorite part of rounds. And I think what makes a team so special. And I like to think of us as asking questions,  we're exploring, we're sharing our different experiences and what we've been focusing on as we're troubleshooting that particular patient. And I think that's really important  because we're all coming from these different perspectives. You know, I come in in the morning, I haven't been there overnight. So the overnight nurse providing their insights  is gonna be really useful. You know, from a respiratory therapist perspective, I'm not necessarily, you know, I know if you ever push into a ventilator machine,  you can see there's tons of settings back in there. You know, and so understanding the nuances of that, how does this patient look as a whole  from a global perspective? And so what I like the most is kind of sharing information and trying to weigh the different things that we're doing.  And so when I think about a, you know, a patient, you know, maybe like ventilator dyssynchrony being a good example, you know, it's not just that they have ventilator dyssynchrony,  but you know, what, who assessed this? What was the objective metric of this? What is subjectively happening? Is this something that's just happening occasionally?  Is it having an actual, you know, effect on their oxygenation and so forth? And so, you know, on my end, I think about medications being really ideally  a last line therapy for ventilator dyssynchrony. And I'm really hoping we're going to have this like in-depth discussion of, you know,  IDE ratios and triggers and what mode they're on and what all have we tried before we move towards, you know, pharmacotherapeutic intervention.  And then, you know, my other classic that I think about is when we think about spontaneous breathing trials, you know, the classic is, well, they failed their SPT.  Well, why did they fail their SPT? How did they fail their SPT? Because sometimes there's, you know, when we start discussing and we dig into that,  I can all of a sudden say, well, you know, it looks like we accidentally gave, you know, a bunch of Ativan right before we did this SPT.  And those types of nuances aren't going to come out necessarily if we're not all together.  And just to sort of piggyback on that question, how do you think that relates to positive patient outcomes, this interdisciplinary approach?  I mean, I think there has been so much that has come out about how an interdisciplinary and multi-professional approach improves patient outcomes.  You know, there was a 50 year review that came out critical care medicine earlier this year that is wonderfully written that discusses  how those outcomes are, you know, are improved. You know, from a specific pharmacy perspective, there is a study that showed that there is a 70% reduction  in adverse drug events by having a critical care pharmacist on ICU rounds with your team. And that was associated with decreased length of stay, decrease in mortality.  We're talking like 20% decrease in mortality. And I know that there are numbers that, you know, are reflective of having each individual member on that team.  So to me, having the more people that you can have there focusing on that patient, the better it's going to be.  Great, thank you so much for that. Okay, Natalie, question for you. And this is sort of a big one.  Could you discuss how COVID has sort of altered your ventilator management in, you know, ventilator management in your discipline? In critical care, how has COVID really changed  how you as a group manage these, manage the ventilator and manage these patients? Yeah, thank you for that very big question. You know, I will say in some ways it has reaffirmed  some of the things that we do, but it's also changed some things. I think we've never been faced with so many patients with ARDS, acute respiratory failure,  in some ways where at least having worked in medical ICU my whole career, this is something we do. We're comfortable with this, we know what we're doing.  But in facing a wave, in facing having to teach a lot of people how to manage COVID, we really did have to go back to our basics and remind ourselves, like,  why do we do things a certain way? And then sprinkle in to focus on the changes. You know, I think a lot more prominent were things like flow dyssynchrony.  You know, we had to think a lot about whether or not we were gonna stick to our guns with our six cc's per kilo, our deep sedation, our paralysis.  You know, I think there were a lot of struggles with that. I think in the beginning, it's not as big of a deal when you deeply sedate a patient paralyzed  as you're getting them through the throes of ARDS, but as they're waking up, you know, as you're trying to come down off the other side,  what do you do when a patient is constantly double stacking? What do you do when, do you keep them sedated?  Do you keep them paralyzed? To what end? So we definitely were noticing, you know, some questions about how we manage, you know, using whether we stick to volume control,  which we tend to do in the beginning in our institution. I've definitely noticed that we're using more pressure control to try to allow for better ventilator synchrony.  The other piece, the other component that seems maybe a little bit more prominent with COVID is the issue of overdistension and PEEP management.  You know, in the beginning, there was a lot, as we were learning about the disease process, there's a lot of questions about the different types of COVID, maybe two types, right?  A stiff one and not so stiff one. And, you know, I think we have become more facile with and more nuanced in how we approach our PEEP titration and PEEP management,  being more mindful as opposed to just sticking with the ARDSnet-RMO PEEP tables, realizing that for some patients that it's definitely not a one size fit all.  We're more attuned to looking for signs of overdistension and, you know, being able to deviate from things like that. And so I would maybe highlight those two  as the main patterns that we've seen.  Great, actually, and to sort of piggyback off of that, a question that just came in is, do you in your institution have sort of an optimal PEEP or do you use a PEEP table?  Have you seen a particular PEEP that tends to work? Yeah, so, I mean, it's a great topic. You could actually have a whole hour just about PEEP titration and then some.  You know, we do tend, because we, you know, we are an academic teaching center. We have, you know, a lot of trainees. We definitely start with the ARDSnet-RMO PEEP table.  So we have that as a standby. But we, from there, we assess the patient. So we, there is definitely not a magic PEEP. You know, we go from, we, after we set it,  so say you initiate a patient on mechanical ventilation, they're newly intubated, they're on 100% FiO2. Routinely, the PEEP will be anywhere from 12 to 14.  I'm just to give a number, since everybody might be asking. And then from there, we would assess. So we would look at the plateau pressure. We might look at the stress index.  We might look at the driving pressure to see if there are opportunities to adjust the PEEP, whether it's up or down from that,  based on the patient's physiology. So there isn't one set number, but we specifically know that there are approaches that we use.  One of the things that we have started thinking about using is esophageal manometry.  It takes expertise. It takes some getting used to. So in our institution, we don't use it routinely. Right now, it's only being used for some research patients.  Instead, we mostly use driving pressure, stress index, things like that.  Great, thank you. And I think some studies have demonstrated that in the beginning of COVID, the management, the ventilator management was very, very variable within an institution  and between institutions. And then some started demonstrating that with time, some things started to become a little more uniform. How long we prone a patient, for example,  what are PEEP strategies, at least within an institution. Carson, from your standpoint,  while no two cases are exactly the same, what trends have you noticed over the several surges that have been most successful from your perspective and with respect to using the VET?  I mean, yeah. So I think, again, such a great question because it just continues exactly with what Natalie's already been talking about and highlighting. And as she said early on,  we have basically just affirmed what we kind of already knew about treating ARDS  and then it just kind of rolled over into treating COVID ARDS.  I think that there was maybe before the first surge of COVID,  maybe there's some doubt about our ability to treat patients with COVID the way that it's like  from an ARMA perspective or from the ARDSnet perspective.  And I think that, like she said, it just kind of narrowed the focus and really like we started seeing a trend towards higher PEEP.  And we definitely affirmed that six mLs per kilogram of ideal body weight is where we should be targeting our tidal volume.  So, and then going even further with a mechanical ventilation perspective,  focusing on the driving pressure. And so really, we start thinking way more about a model study and if our driving pressure  is trending higher, maybe this patient's a lot sicker than we initially thought. And so we also have been using the driving pressure  to do PEEP titration  because there hasn't really been any great evidence so far that has said that esophageal manometry versus doing PEEP titration with driving pressure  is it has any significant outcome. So I see the value in using esophageal manometry, but unfortunately, EpiVent2 didn't really show  any great outcome in terms of titrating PEEP that way. So, I mean, I look forward to more research in that area, but we can use whatever PEEP titration works  for our institutions.  And Carson, have you seen the trends over the last searches of particular mode that your institution has worked best or is it really patient dependent?  I think an individualized approach is probably what we've seen the most. We do tend to use a lot of volume control while they're in the MICU.  If they are cannulated and they end up with CT surgery, we've seen a lot more pressure control when they're on BV ECMO. I think that that was something,  particularly in the first two searches, I saw a lot more pressure control, particularly after patients were cannulated and on ECMO.  Okay, great. Natalie?  Maybe Natalie had something to add there. Yeah, I did, sorry. I picked the wrong button.  I think it's really great to hear, Carson, because that's very similar to what we do. I would add one thing, which is working with others in other institutions.  I think every institution has their go-to mode that they're the most comfortable with. And I think that makes the most sense to stick to that. We choose volume control in our MICU  mostly because it's the easiest for us to teach mechanics, right? You have your PEEP pressure,  you have your plateau pressure. It's relatively easy to understand compliance that way.  And especially early on, for the most severe ARDS patients, you primarily don't have to worry too much about flow to synchrony because there's the data and paralyzed.  That's where I think my bias goes, as we're waking them up, volume control becomes a problem because you start having more of your flow to synchrony.  So that's what we've found over time. Our teams have become more and more comfortable switching over to pressure controlled modes because in those settings,  there's more flow variability. You have less problems with the flow to synchrony problems. And I think in that way, I think it's been a nice expansion in our skillset  for what it's worth. I absolutely agree with that. And I think 2018, one of my mentors and professors from undergraduate, Lonnie Ashworth,  wrote a really great article about pressure control and about some of those nuances and where it can really come in handy. I think that it's important to highlight  if you do make that move from volume control to pressure control, that it takes a lot more nuanced approach and the respiratory therapists  need to be much more keyed in on the details of the mode  so that when you start to see fluctuations in volume,  for example, that you are addressing it in real time and immediately. So it just takes a lot more focus to manage pressure control.  And then sort of related to your reference to dyssynchrony,  Carson, is there particular things that have you found have worked to help with a patient with dyssynchrony in addition to changing the mode?  Yeah. I mean, I think that both Natalie and Andrea have kind of already talked a little bit about the importance of isolating  the type of asynchrony that the patient is experiencing. I think a lot of times it's really easy for us to come to the bedside and be like,  well, the patient is dyssynchronous. Well, what kind of asynchrony do they have? Like, I want to know if it's an early trigger or a late trigger, if it's a flow asynchrony,  like we've seen COVID patients  are working so hard to breathe and just really want more flow. So there's so many times in my career that I think back on even before COVID where the team at the bedside  is ready to re-sedate, re-paralyze, and the respiratory therapist is able to come in and dial in the IDE ratio appropriately or change the flow appropriately  for that patient's needs  and avoid re-sedating. So we make Andrea's job a lot easier by being able to make one change on the ventilator, but it really does take that expertise  from the respiratory therapist at the bedside to analyze the waveforms correctly, decide what the appropriate change to the ventilator is in the moment,  and then hopefully we can move towards the ultimate goal of extubating the patient. And I think that when it becomes really challenging  is when the patient's just on the cusp of recovery, because it's like kind of this,  you want to move towards pressure support ventilation, you're weaning towards pressure support, but has the patient fully recovered from the initial acute illness?  And so there's a fine line that we work  between re-sedating the patient and maybe switching modes to pressure control.  Great, thank you. And you mentioned many things that we can do at the bedside with the ventilator for dyssynchrony. The reality is sometimes sedation is necessary  and sometimes for hypoxemia, neuromuscular blockade is necessary, and these patients can be very challenging to sedate in the pharmacotherapy that's involved there.  Andrea, what have been some of your strategies and what have you seen with respect to the use of neuromuscular blockade and sedation with these COVID patients  while they're intubated?  Yes, so this is kind of a big question, but I'll do my best to give a good answer here. So I think when stepping back, I think in the beginning of COVID,  where there was a lot of disarray among our standard ICU practices, which we've already kind of been discussing. And I think we had kind of never seen anything like it,  which kind of forgot our best practices. But I think as we've gotten more familiar, we're finding that COVID is really a lot like many other critically ill patients.  It's a lot like other ARDS patients. And I think that really brings us back to kind of the best practices for sedation and analgesia management in the ICU,  which is gonna follow our PAD-IS guidelines. And so thinking about treating the patient's pain, optimizing ventilator synchrony, and then keeping that light goal of sedation,  so zero to minus two. And additionally, keeping in mind that you may or may not need sedation in order to keep the patient at that level. Now, certainly you might,  and there are patients that we all think of that needed quite a bit to get there. But I think just because you had a patient that needed quite a bit does not necessarily mean  that every patient does. You know, again, propofol, dexmedetomidine are gonna be our first line agents. Anytime we can avoid a benzo is gonna be really good.  I just finished Dr. Wes Ely's Every Deep Drawn Breath, and it's a really powerful book about kind of the history of delirium and post-intensive care unit syndrome  and where we're going with that. And I think, you know, he had this kind of funny term where he said COVID created like a perfect delirium like factory.  Like you almost could not create a better scenario to make delirium happen than to have this like very intense respiratory disease that puts you on a ventilator.  And then we isolate you from all of your friends and family and everyone's wearing those like suits. So now you're delirious on benzos and there's like some guy  that looks kind of like a ghost in your room or something like that. And I think that that's really important for us to remember that, you know,  it's not, we're balancing treating COVID and managing that, but also that, you know, when they get out, you know, an ICU stay is not benign, you know,  and that was one of the more powerful stories in that book. I mean, one of those patients lost like 30 to 40 IQ points just from that experience.  So, you know, I think we saw kind of a lot of stuff, but I'm hoping that the emerging trend that we're seeing in COVID management with sedation and neuromuscular blockers  is actually going back to kind of what we already knew. I think an important thing to think about is that we have had a fair amount of drug shortages.  I think drug shortages have allowed us to be maybe a little bit more creative in certain things, but I think there are two trends that I'm very interested by  that I hope will continue for ICU care or us to look at more. One is using ketamine. You know, ketamine does not even make it into the PADIS guidelines, I don't think.  And yet it really is a wonderful drug and has a lot of potential benefits. And so I think when we saw shortages,  we started to use ketamine more frequently as a sedative agent. And I think, you know, it has opiate sparing properties. It's not a benzo, which is a huge advantage.  And another thing has been looking at, you know, basically using intermittent boluses for neuromuscular blockade. And, you know, so originally when we think  about neuromuscular blockers in ARDS, we're thinking about, you know, the ROSE trial, we're thinking about socetricurium for 48 hours at the flat dose and so forth.  And, you know, I think there's a lot to be said for that, but I think what also we're seeing is, do we really need that necessarily? And kind of where are we going with that?  And so, I guess some things again is to think that like, again, when I was preparing for this talk, I can't tell you how many times I saw COVID ARDS looks a lot like regular ARDS  and in terms of how we're managing it. And so that has to, you know, remind us that neuromuscular blockers are a last line treatment, a rescue therapy for severe, you know,  oxygenation issues and dyssynchrony that we cannot fix other ways. And so I guess I would say what I'm most interested in is essentially the fact that we can maybe do these boluses.  And I maybe would open this back up to all of you is, you know, at what point, you know, you see someone who's dyssynchronous, we go in and we look at the, you know,  see what settings we can adjust. And then we give, you know, one bolus of broccuronium potentially. And then do we assess right then?  And how do we keep that assessment going?  Again, I think a huge advantage of this is potentially we're sparing neuromuscular blockade, which is excellent in many ways. But the other side is logistical challenges  of you have to make sure that patient is appropriately sedated. And so how do you make sure that they're, you know, RAS minus four to five versus our usual goal  of zero to minus two?  Yeah, I'm glad you mentioned ketamine. We're a big ketamine shop and it has been very successful for us as well. Are there just, as an additive to that,  are there particular oral agents that you have added on that have been helpful to reduce the number of infusions and sort of wean them off of infusions?  Anything that's worked for you in particular?  Yes, we have used at my institution in particular a fair amount of, you know, basic oral oxycodone, but I am personally a big fan of methadone, you know, and there's a really,  there's a great study that was even the pre-COVID era looking at basically using methadone.  I think it's 10q6 to wean off of fentanyl. And I think that that is a great strategy for these patients. And, you know, I think that is something  that we probably can be thinking of, you know, I was always kind of hoping we would do it more often before then. So again, sometimes I hope that COVID  is gonna bring about some good habits that we maybe we should have always been looking at more frequently. But yeah, I think methadone is a great option.  I think one thing just for the, you know, the crowd to be aware of is that the titration is very interesting with methadone and there are very kind of specific protocols  that should be used for that.  But nonetheless, I think methadone is a wonderful one for sure. Yeah, that's what we use a lot of methadone. And again, with the assistance of our pharmacists,  so that again, bringing back to the multidisciplinary team that's been so incredible, you know, during this pandemic.  So, you know, on that note, something that does sometimes require a lot of sedation is when patients are hypoxic and proning is required.  Can you discuss Natalie, sort of your thoughts on proning,  you know, the frequency of proning, how often are you proning, the duration of proning, what are you using at your institution now and is it uniform? Yeah, happy to.  So, you know, it's interesting just to tie it into what Andrea was saying about paralytics. You know, we were an echo shop, that was our go-to whenever some patients get sick  and then we ended up with our paralysis trials, right? And then we ended up with our proning trials and all of a sudden, wow, we actually have something  that it's not, you know, advanced technology, very niche that we can offer for patients with severe, you know, ARDS. So far and away still, we stick to that, right?  It's protocolized, a patient's very, very severe, they get intubated, they get sedated, their peep is titrated, they're 100% of how to and then we do paralysis and proning.  And that's way before we will even consider ECMO, although ECMO is always hovering in the background. With regards to proning, it, you know,  we're pretty consistent, it's pretty protocolized. So we have our, it's pretty well choreographed actually, it's beautiful to behold actually when you watch our team,  it's actually the epitomizes the concept of the interdisciplinary team really. So we will prone the patient and keep them proned, right?  So the key is it has to be over 16 hours consistently. So we keep them proned, we definitely are mindful and watch to see what happens with the blood gas,  although there isn't really yet data that shows the blood gas change corresponds to true response to proning, it is something that we like to use at least clinically to hold on to.  And then we'll keep them proned and then we'll supinate them just for a break, regardless of how hypoxic they are, we will supinate them as a break from being on their bellies  and then usually within an hour or two,  at least in the first day, unless they're magically better, which often they are not, we will again place them in the prone position. In terms of the timing, what we will often do  is work with our nursing colleagues to figure out what's the best ideal timing. So 16 hours plus a couple hours there doesn't make 24. So what we will often do is shift a little bit  so that eventually our supine time tends to be in the morning and during rounds when we're there, we might be able to get our chest x-ray done or if there's procedures to be done,  that way it can be coordinated. But the thing that we are very consistent about is the prolonged duration of proning.  At times, I will say, and this is not in the literature, we find patients that are really refractory. Maybe they're not an ECMO candidate, they are better on their abdomen,  but they're really marginal. We have pushed the duration of time that they're in the prone position for longer than 16 hours, sometimes across 24, just partly out of necessity  because our concerns about the patient's stability. And we haven't found issues with that. Nurses have done an amazing job just trying to prevent pressure ulcers  and other injuries from that. But I think it's just something we just gauge based on what we see. And then in terms of weaning, we're pretty consistent.  You know, we march down on our FiO2 and our PEEP if we manage to get it down to 60% and a PEEP, you know, in general, our rule of thumb is PEEP of 10,  but you know, as we said before, we sometimes titrate our PEEP specifically to the patient, but 60%, and then what we will do is if they're in the supine position,  their P to F ratio is above 150, we are okay with stopping the proning at that point and then allowing our continuation. Sometimes our discussion there becomes,  well, do we stop, when do those paralytics get stopped in conjunction to proning? Like, how do you undo your protocol, step our protocol as you come back down?  And I don't know that we're as consistent about saying, all right, well, let's keep proning until the paralysis is fine and the other stuff is off.  I think that part we individualize to the patient.  Then when would you say, a question that came in, would you say, you know, the patient has failed a trial at proning, so you prone a patient,  their SAT was 89 and then you prone them and now their SAT is 84%. Do you, you know, do you give it another hour or two or do you say, okay, this is a failed patient,  let's put them on their back, or do you even try putting them on their side? You know, is that an option? Yeah. Yeah, that's interesting. I think we tend to wait a little bit.  We give it at least a few hours because just the process of turning, sometimes you can lose some ground, but with some time, sometimes you can gain that back  because it's almost like you put the effort in to put them on their abdomen. So unless they are, you know, truly unstable, we wouldn't necessarily turn them back  on their backs immediately.  I don't know that we have specifically tried the side. I know we have done that for patients, totally unrelated patients who are self-proning,  you know, so not ones who are not intubated, but we try to encourage the self-prone who can't tolerate it. So we'll say to them,  oh, why don't you just try being really on your side, maybe just as a compromise, but no data for that really, right? That's just an instinctual thing, but we haven't done that,  at least with our intubated patients.  Great, thank you. Karsten, where does nitric oxide or e-propanol inhaled sort of fit into this from your perspective and anybody else, Andrea can answer this or Natalie.  You know, in the algorithm is, do you all use either e-propanol or nitric oxide before proning, not at all? Have you found it to be beneficial?  I know that the literature has not suggested thus that it has been, but people are still using it. Yeah, I think it's really important to highlight  that the literature hasn't supported it, but observationally, like it's what a phenomenal time we have seen with nitric oxide being very successful in bridging these people.  Unfortunately, I think what ends up happening is that we're kind of using it as a bridge between paralysis and proning, but they end up staying on it because they are,  it does work so well. And it's kind of then the last device to come off before we really start weaning towards extubation. So after they've successfully marched down  the FiO2 and PEEP, as Natalie was saying, and we're getting ready to make that transition towards pressure support ventilation,  then we're really working on getting the nitric oxide off. I think the reason that we've favored nitric oxide more than velutri or epiprostanol, I should say,  is as an aerosolized generating procedure.  So we're favoring nitric oxide because we're trying to keep our staff safe. So we don't have that continuous nebulization happening.  We kind of use it as a last line of defense if we ran out of nitric oxide. And there was definitely nights, particularly in this last surge  where we saw the disease process shift a little bit from the lungs to the airways where we had nights where we had 15, 16, 17, 18 patients  on nitric oxide. We were running out of tanks  and needing to order more emergently.  But we really did see some value,  at least observationally with nitric oxide. I don't know if Natalie, if you had a similar experience or not.  This is interesting actually to listen to how other people do it. We try not to be too hooked on nitric in that, as you said, there's really not true data  that proves that there's actually mortality benefits. So we really do our best to use what's been proven in the studies when we can't help it.  So we use it to bridge to paralysis, proning, ECMO,  but we will try to wean it off sooner if we had a choice because that's maybe not the thing that will help the patient in the long run based on data.  That said though, we use it, we use it quite a lot. Unfortunately, I feel like our NICU probably is skewed because being an ECMO center, we probably have the sickest of the sick.  So unfortunately, a lot of what is evidence-based gets interpreted and then expanded in our units and our patients. So I think I would consider nitric and inhale flow  in that category of just things you can probably pull out, but probably not something you should think to use consistently. Yeah, I totally agree.  I just think it was so interesting the volume that we saw and it seemed to at least bridge a gap somewhere in the care of these patients.  Yeah, I think the one thing that was really cool, I mean, not cool, but I think there's a benefit from it is that because the team got so used to seeing  acute respiratory failure, ARDS, everybody knew they got intubated, that they knew how to set the ventilator, the sedation was on,  so the kind of being caught off guard and needing some time was, you know, that was less common. I think we were, it was quite nicely protocolized and so that was nice to see.  I think- Can I ask you all a question? Sure. Sorry. I was gonna say for both epiprofenol and nitric, was there a trial period that you guys would start it and then you say like,  okay, we saw this improvement in this metric and then we used it or what were you guys looking for and how did you trial it?  I don't know.  I don't know if I can say if there was necessarily a trial time necessarily. It was just, we would get to that point where the patient is on 100% FiO2  and we've maximized their peak with titration trials the best that we can and maybe we're on the fence about whether or not we're gonna prone them or not  and it gets started, you know, again, it's not like our first line, it's not ideally what we would go to since there isn't really evidence supporting  the improvement of oxygenation with epiprofenol and nitric, but we would end up probably leaving it on  because it was already there and we did start to see some improvements with that bridge. So it's hard to say and again, I think that this is,  it's nuanced because it is individualizing it to the patient. Some patients responded better and we would turn it off right away versus other patients that responded very well to it  and we, again, Natalie, if that's a similar experience.  Yeah, no, we're pretty consistent with saying we use it because they're desatting and we can't, you know, we can't stabilize the situation.  We look for oxygenation as the response pretty much. So we look at the sat, see if the sat goes up. If it's nitric, it's usually just off the top of our heads,  20 parts per million, let's see and if it's flow land, which I agree with Carson, we had not been using really much at all in the setting of COVID at top, at max 50  and then, you know, just see if they respond. At that point, trying to catch up with any part of the protocol that we haven't instituted yet  and then, you know, sometimes, you know, even despite that, right, they're paralyzed, they're prone, they're on nitric, they're still hypoxic, you know,  that's where we have to think about ECMO and the nitric stays on, right, because we need to keep them until they're stable and then, eventually, the nitric comes off.  Once that's now stable, then we take it off.  Yeah, I think, Andrea, to your point, that's often what happens, I think, is that the nitric gets added at some point during their hypoxemia  and different people are doing it slightly different. Some are doing it before proning and neurovascular blockade. Some are doing it in between or at the last, you know,  when nothing else is working but even if it's not working tremendously, if they're still hypoxic, people are reticent to remove it because what if they were to rebound and get worse  and then you have a very expensive medication that's being delivered with really no benefit that can kind of linger on. So that can be a challenge  and I'm sure from a pharmaceutical perspective that's, you know, from your area, it's challenging.  I think another question that has come in, HEPA filters.  Carson, how protective do you think they are? Do they really protect the environment from aerosolization? Are you using them?  Yeah, so I think that we moved all of our COVID population  to areas of the hospital that we could use negative pressure in the rooms. And so as far as standalone HEPA filters, I, you know, I've seen them.  We have multiple hospitals in our system that are close by. So I have seen them use like the standalones with in the absence of negative pressure.  But I think that in terms of protecting ourselves, you know, I think that we got really good at PPE and in the very, in the first, I just remember,  I'll never ever forget the first COVID patient that was admitted to our MICU. And we were just like all like, you know, we didn't know what to do, you know,  but we've gotten so good at protecting ourselves  with PPE. And so I don't know if I can necessarily speak to that, but I think that there is some evidence that supports using,  I think that there was some abstracts this year at the AARC Congress surrounding using like SPAG type units  to clear aerosol out of the room and keep protected. And that showed some pretty decent results in terms of protecting staff.  Great, thank you. And then while monitoring these patients, both from an oxygen level, as well as a CO2 and pH level,  I guess Carson, I can ask you this first and then both Andrea and Natalie can comment afterwards. Are you, do you measure ABG serially, VBG serially? Are you using an end tidal CO2  and watching oxygen saturation by pulse ox? It depends on the patient. What is your usual strategy? Yeah, I mean, I think that our trend even before COVID  was really to focus on the SPO2. So it, you know, we would of course validate that with an ABG as needed, particularly when we're getting ready to prone patients,  I think it's important to focus on ABGs. So Natalie kind of said earlier that there's maybe limited evidence in terms of trending it.  But, you know, at least initially to manage the patient and see if there is some response to prone positioning or, you know, if we are meeting that threshold  of less than or equal to 150, a P to F ratio of less than or equal to 150. And then once the patient's stabilized, I think we see a lot more ABGs.  Really we're only using end tidal CO2 after the intubation and for airway management.  Gotcha, and is there a significant emphasis on trying to get the oxygen levels down? There's a lot of also discussion about these COVID patients requiring so much oxygen  and then the oxygen therapy winds up being toxic to the lungs and therefore further injuring the COVID lung. Yeah, that's the hard part, isn't it?  Because if we're focusing just on the SPO2, we don't necessarily know what their PaO2 is. And so we are trying to bring down the FiO2 that we're delivering in a stepwise fashion,  but we end up kind of going slower probably than we do in some of our other MICU patients.  So sort of on that topic of oxygen, you know, very early on in the pandemic was this concept of the happy hypoxic.  The patient that came in to the emergency department and didn't look particularly ill and yet was desaturating significantly. And there has been throughout the last two years  several discussions about the timing to intubate. We're going all the way back,  the delaying of the intubation.  So Natalie, do you have a particular strategy or a particular index, like a ROCS index or something that you use to determine when a patient should be intubated  or is it just the clinical environment in general? And do you believe in delaying intubation until absolutely necessary? Yeah, very loaded question. Yes.  I probably question myself depending on the day and what patient I see in front of me. So ROCS index is very attractive. And I have to say, when I looked at it,  I was like, oh, that's kind of what I do, right? I see what their work of breathing is, what's their respiratory rate. Although I think it's interesting,  the observation about what the ROCS index threshold is depending on how, like right after they were on high flow and then hours later. I think there was some papers,  I have not caught up on my reading yet, but some papers that are looking at ROCS index in COVID patients. And it sounds like it's not great, although what's the harm, right?  And having that information as a reference.  I will say, unfortunately, for lack of a better answer, it's really depending on your environment, right? It's depending on the patient. Sometimes we will see trajectory.  If it's rapidly worsening, we might move towards intubation. I definitely think we've swung to the other side of waiting until it really is necessary.  And I don't know if that necessarily means it's worse for the patients. Although I think what that has occurred then is the patients that are ultimately intubated  are probably the more severe of all of our patients. So it's hard to interpret what's the right threshold, I think.  But I do think some are starting to question whether or not we're waiting too long. And maybe if we're willing to dare go back to doing it a little sooner,  then maybe these patients will do better. But when we see all of these patients who are intubated, COVID in our ICUs for days and days, sometimes weeks and weeks on end,  it's really hard to feel like this is the time to commit to a patient to that. Natalie, I have a group text of friends, respiratory therapists from around the country.  And oftentimes somebody will ask a clinical question in our group text. And a lot of times the answer is, it depends.  Danielle, when you asked about the time to intubation, the happy hypoxic, I immediately jumped to a patient that was recently admitted  that was kind of that happy hypoxic,  that it kind of fit that, she fit that mold.  And she drove herself to the emergency room. And when they arrived, her stats were 60.  She remained on BiPAP for a time, but then it got to that point is when do you decide to intubate? So that story, I guess, leads to another question for Natalie is,  this patient was particularly interesting because she was immunocompromised. Does that play any role in your decisions to intubate sooner or later?  It's interesting. And I'm not sure that it would in particular,  I think more so just to be careful in watching what kind of the work of breathing and how much reserve the patient has.  Because I feel like you intubate and you might introduce a whole other risk of ventilator-associated pneumonias. And is that necessarily something  that's gonna help the patient either? So I'm not sure that, at least personally, if that affects my decision. I'm just curious because it was interesting  to see her in the ICU on BiPAP, texting and interacting and everything. And then we use that term happy hypoxic, but then once the patient's intubated,  they decompensate very quickly. So it's like, okay, well, they seem to be awake and alert and interacting with us. But then once we intubate them, the decompensation happens,  not over a matter of hours, but over a matter of an hour. And then they just never really recover. And suddenly they're paralyzed and prone. And we're doing all of the things  that we've already discussed during this hour. I mean, to be clear, I think- So I recall- Yeah, go ahead. I say, I recall there was an interesting editorial by Martin Tobin.  And it was, I think, something about physiological principles. But he had this part about thinking about the circular thinking of a patient is intubated  and then you're like, oh, they require intubation. As opposed to, did they need to be intubated? Or they're on BiPAP, well, do they need BiPAP? And so the question I guess I have  like that kind of patient is, okay, she had a 60%, she was on BiPAP. It sounds like she probably needed BiPAP. But then you intubate her  and all of a sudden does your psychology change to, oh, she's intubated and it's 60%. Now I need to go do all of these things. And does that, again, that circular thinking  send us down a different pathway?  I just would be curious to kind of think about that. Because I was another concept of like, when you see someone who's awake and interacting,  you treat them differently than someone who's asleep in the bed because we've sedated them. Even though if we had not sedated them, potentially they could still interact.  It's an interesting thought, Andrea. I mean, I was gonna say, you mentioned the patient was on BiPAP. I mean, in my mind, that's still positive pressure ventilation.  So we are kind of changing the equation a little bit. And when we're still, we don't measure tidal volumes as carefully when we're on BiPAP, but there's still risk to doing that.  But not the additional risk of sedation and all the other untoward effects that happen once you really have to take the patient out of the camp. There is actually a recovery RS.  There's just a published in JAMA that goes over actually potentially the benefits of CPAP compared to high flow and avoidance of intubation. It's gonna be interesting  because we don't use CPAP all that much for us.  So that said, I think that we don't know,  we just can't measure, right? How much these happy hypoxics are potentially injuring their lungs just by their own work, right?  There's this concept of patient self-induced lung injury, my favorite term now, PCILI. So there's a risk, right? That they're injuring themselves. We're just not doing it to them.  So we're not, we're kind of looking the other way. So in theory, they could be injuring themselves and we're not protecting them by sedating them and giving them only six CCs  and measuring their pressure. So it's, I think a toss up and there's just not enough data for us to know, which is why these larger studies  might be able to give us some information. In the end, we just kind of have to trust our instinct, I think.  Yeah, that is probably the biggest challenge of COVID is that question is when to intubate. I think on the other extreme, when to extubate is a lot easier,  but when to intubate has been the profound challenge. And just to add to what you're saying is that there is the aspect of nutrition when patients are on BiPAP for days and days,  they're really, you know, even getting a DOP off or a feeding tube, you know, breaks the seal. So patients can lack nutrition for many, many, many days  and then you're behind and the neuromuscular, you know, weakness that ensues after the patient's intubated and not moving much. So that's always something to consider.  There is a question that's coming in about, for you, Andrea, about propofol  and how you monitor triglycerides and how you deal with the potential for propofol infusion syndrome,  you know, and from your standpoint, how do you monitor that and recommend the team monitor that?  Sure. I think this is a really great question. You know, I think to just to back up, you know, it's generally my threshold for when I started to get worried about  are we at high levels of propofol? And I thought something about Chris is 60. That's kind of my soft limit and anything under 60, I'm not super concerned about high triglycerides  and stuff like that. Generally speaking at our institution, we monitor like every three to five days just to kind of see where we're at, you know, get a baseline.  If someone's at 80, you know, you're not as concerned as if they started off at 350 or something like that.  And if it starts to be, you know, you start to kind of trend a little bit higher, you've order labs more often. My harder max is 80 of propofol.  That's kind of when I started to get a little bit nervous about like, okay, this is a lot of propofol for this patient. You know, so that's when I started thinking about,  you know, ketamine, other agents, how can we get creative to bring that down that threshold below 60?  My general cutoff of like, we absolutely have to kind of stop propofol and move to something else's 500 for triglycerides. And I will, depending on kind of what the trends are,  I will let numbers that are in the higher range ride for a couple of days to see kind of where we're going. You know, I think PRRS is, you know,  much more common in children than it is in adults. And I think with appropriate kind of monitoring,  even with, I think if you're generally under that kind of 60 threshold, it's a relatively rare phenomena.  That's a great question. So yeah, generally baseline, every three to five days after that, and more frequently if it's high, 500 being kind of a hard cutoff.  And between 60 and 80 of propofol being a time to start getting creative with what other agents you can use.  And obviously when patients are on a lot of propofol, then as an interdisciplinary approach, our dieticians have to change the caloric intake,  depending on how much propofol that someone's receiving. And that amount of feeding can also alter when a patient's supine versus prone. So one of the questions that's coming in  is how do you all manage? So Natalie, how do you manage feeding in a patient that's prone? Is there, does your protocol change your two feeds,  for example, or is it the same NPO completely? How do you all manage that? We definitely feed. I don't know that it's really managed differently, except we might pause the feeding  during the process of turning the patient, just to avoid aspiration, but we've definitely wanna continue. That's pretty much our approach.  Great, thank you. And then with respect to, let's say, with all these strategies, proning, neuromuscular blockade, inhaled nitric oxide, whatever you may use, your Decatron,  finally all the magic actually works, and the patient does better, and you're in position to potentially extubate somebody. What do you think leads to a successful extubation  and a sustainable extubation? What are the parameters that you use? Maybe Karsten, you might wanna add to this. The parameters you might use to say that this patient is ready,  and we believe that this patient will stay extubated in a COVID patient. Yeah, that's a really great consideration.  Especially in the first two waves of COVID, we were seeing,  I'm not sure, no, that's not true. We have continued to see that throughout the pandemic, is upper airway edema, a lot of secretions, very thick secretions.  So in order to preserve equipment in the first wave, in the first, literally first days and weeks of COVID, we were trying to use HMEs, and that didn't work.  We needed to heat and humidify the circuits the same as we would for any prolonged mechanical ventilation because we were actually having to extubate  and reintubate these patients with such thick secretions. But really what that boiled down to was a very edematous upper airway.  And so we have instituted using leak tests as a way of making sure that the patient who's passed an SBT can actually sustain their airway after they're extubated.  And if they fail a leak test, we reinflate the cuff and give them steroids and then wait 24 hours and do another cuff leak test before they're ready to be extubated.  Recently, I was caring for a patient that hadn't had a successful cuff leak,  but getting them extubated was extremely important. And so we went ahead with extubation and we extubated the bi-PAP.  One patient was morbidly obese and had just a week earlier been being proned and had many complications from mechanical ventilation. So in the first hour,  very successfully tolerating extubation on CPAP,  on just CPAP of 10,  I went in to wean her to a high flow nasal cannula  because she seemed relatively stable and immediately heard Strider. So we had to do three back-to-back doses of racemic epinephrine and get the Strider  under control that way. And then she tolerated being on high flow nasal cannula relatively well after that. So it was an interesting case  and I know that that's one individual, but it seems that extubating to a high flow,  again, using 60 liters a minute of flow in order to meet their flow demands and then whatever FIO2 that they need for oxygenation seems to be working.  But there may be those cases where CPAP or bi-PAP is appropriate to extubate to for sustained success off the ventilator.  Yes, and of course, feeding into that is the timing of tracheostomy,  which is, I think also has changed dramatically from the beginning of the pandemic to now just to comfort level and when patients are receiving a trach  in order to wean off a ventilator. Just real quickly before we end the session, I don't know, Natalie, if you want to add to that, when is your sort of timing of tracheostomy?  When do you start to consider it and what's comfortable in your institution? And are you doing percutaneous trachs at the bedside versus the operating room?  Yeah, I will say, I definitely, again, big caveat, our skew is that we have the sickest of the sick COVID patients. So it's almost rare when we're talking about extubation,  like, oh, yes, we do extubate COVID patients. So yeah, with trach, I don't know that we've changed our timing. We still think about two weeks or so, maybe they can get better.  So we kind of wait until the two weeks. Well, as we're headed there, we start thinking about whether or not this is within their goals of care. We do do percutaneous tracheostomy.  Although with COVID, there was all the, must test them before and make sure they're in a negative pressure room because there's a risk to the operators.  But I don't know that it has necessarily changed our approach to when we do it, although it has happened quite a lot, unfortunately.  In fact, the interesting thing that we're facing right now in our hospital is they do ultimately get better, which is a wonderful thing. And then whether or not they're still stuck  in the hospital, how to decamulate the trachs. And that's a whole other challenge, which is interesting. We've never had to deal with that before.  But I guess that's a good thing. That means our trach patients are getting better.  Great, thank you.  So I think that concludes our question and answer session. Thank you, Andrea, Natalie, and Karsten. 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.sacm.org  forward slash webcast forward slash. And that concludes our presentation today. Thank you so much.  Thank you.

Video Summary

This webcast featured a panel of experts discussing various aspects of COVID-19 ventilator management from an interprofessional perspective. The panel included an Associate Professor of Critical Care Medicine and Anesthesiology, a Vice Chair of Clinical Operations at the Department of Medicine, and an Education Clinical Specialist in Respiratory Therapy. The experts answered questions from attendees on topics such as successful interdisciplinary approaches to ventilator management, how COVID-19 has shifted ventilator management practices, the use of neuromuscular blockade and sedation, the frequency and duration of proning, the use of inhaled nitric oxide and ephedrine, and the management of feeds and nutrition. They also discussed the timing of intubation and extubation, the monitoring of triglycerides during propofol administration, and the parameters for successful extubation. The panel emphasized the importance of interprofessional collaboration, patient-centered care, and evidence-based practice in COVID-19 ventilator management. They also highlighted the need for individualized approaches and the consideration of potential complications and risks associated with different interventions. The webcast concluded with a discussion on tracheostomy timing and the challenges associated with trach decannulation in COVID-19 patients. The recording of the webcast will be made available to registrants within 24 to 48 hours.

Asset Subtitle

Pulmonary, Procedures, Infection, 2022

Asset Caption

During this webcast, a multiprofessional panel of experts reviewed strategies to develop a multiprofessional team approach to COVID-19 ventilator management and discussed how each clinician's role contributes to optimal ventilator management.

Moderator: Danielle Davison, MD
Panelists: Andrea Sikora, PharmD, MSCR, BCCCP, FCCM; Natalie H. Yip, MD; Karsten J. Roberts, MSc, RRT, RRT-ACCS, FAARC

This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number 1 NU50CK000566-01-00). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). Its contents do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.

Meta Tag

Content Type Webcast

Knowledge Area Pulmonary

Knowledge Area Procedures

Knowledge Area Infection

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Nonmember

Membership Level Professional

Membership Level Associate

Membership Level Select

Tag Ventilation

Tag Mechanical Ventilation

Tag COVID-19

Year 2022

Keywords

COVID-19 ventilator management

interprofessional perspective

neuromuscular blockade

sedation

proning

inhaled nitric oxide

feeds and nutrition

intubation and extubation timing

triglycerides monitoring

tracheostomy timing

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.