Hello, and welcome to today's webcast, What We Learned from the COVID-19 Outbreak in Wuhan. This webcast is being recorded. The recording will be available to registrants within 24 to 48 hours. To access, please go to covid19.sccm.org slash webcast. And now, a few housekeeping items before we get started. Please note the disclaimer stating that the content to follow is for information or educational purposes only. The data has not been peer-reviewed. It is based upon a small sample size with key aspects of information missing, and a single center experience. Advice is based on expert opinion. Throughout the webcast, please feel free to enter your questions into the question box. All questions asked via the question box will be answered offline and posted on the SCCM COVID-19 Resources webpage at sccm.org slash disaster. Our speaker today is Dr. Zhiyong Peng. Dr. Peng is an adjunct faculty member of Center of Critical Care Nephrology of the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, and an intensivist and medical researcher at Zhongnan Hospital of Wuhan University in Wuhan, China. Dr. Peng is also the Chair and Professor of Critical Care Medicine of Zhongnan Hospital and the Vice Director of Center of Clinical Trials of Wuhan University. Dr. Peng has nothing to disclose. I will briefly talk about the following contents. First of all, I will talk about how to prepare for the outbreak of COVID-19. In the early stage of the outbreak, the medical resources always limited, including the medical beds, ICO beds, or medical professionals. We need to mobilize the medical resources, either the help of the hospital authority or government. We need to organize new teams to set up more ICO beds. The more ICO beds, the more patients will be saved. My approach is to recruit the physician with a similar training background, such as the anesthesiologist. Actually, it demonstrates this works well in my city. Another issue is personal protection. Safety is top priority. We need to prepare enough PPE, including gloves, gloves, protective shoes, N95 mask, goggles, face shield, and hood. We also set up the precautions for droplet, close contact, and airborne. We set up the protocols to how to wear the PPE and how to take off the PPE. We put the camera inside to monitor everybody to make sure everybody follow these protocols. We also monitor the ICO environment regularly for the virus to make sure all the staff's safety in the ICO. Actually, the transmission in the hospital is quite often. Our previous study shows that the hospital-related transmission is quite often, and 40% of our patients are related to the hospital transmission, and the majority of them are healthcare workers. The interesting thing is most of the infected healthcare workers are not from ICO, not from ER. They are mainly from the general world. The main reason is that initially they don't know the severity of the transmission. Another issue is that they are affected by the untypical patients with COVID-19. This kind of patients came to the hospital with the abdominal pain, diarrhea, and they came to the internal medicine, they came to the surgery, and then they affected the medical workers there. We also need to set up the policy for triage, including the favor clinics, ER, the general world, and the ICO. And we need to set up the admission criteria for the general world and also for the ICOs. Next, I will mainly talk about how to manage the critical real patients with COVID-19. This is the patients in the first month admitted in our ICOs, and they are including the general features about age, comorbidities, and the scoring system in the ICO admission. And you can see the survivors were relatively younger compared to non-survivors. This is the variables measured initially in the ICO, including the lung size, P4 ratio, carbon dioxide, and the PEEP. And you can see the survivors always with the relatively higher lung compliance compared to the non-survivors. This is the level test in the ICO admission, including the white counts, liver function, kidney function, trouble level, and IL-6. And you can see the ICO survivors relatively lower IL-6 and relatively lower white counts. This is the treatments and outcomes for this group of patients, including the ventilation support, medications, and complications. And this group of patients were very sick, and 28% of the patients recovered with only non-invasive mechanical ventilation, and 72% of the patients requiring invasive mechanical ventilation, and half of them switched to ECMO. 94% of the patients complicated with ARDS, and 64% complicated with heart problems, and 22% complicated with AKI, 34% complicated with secondary infection. These are key points for ventilation supports. From our experience, non-protective approach is extremely important. Plunge the patients as early as possible. Evaluate the mode parameters frequently, and switch, if not appropriate, titrate PEEP and titrate volume based on the transpulmonary pressure, if possible, or driving pressure. Keep the driving pressure less than 15. Prevent acute cardiopulmonary. Be careful of non-recruitment maneuver. Set the highest PEEP at 20. Here, I mainly talk about how to choose the modes of ventilation, and when to switch the modes of the ventilation. First, I will talk about the high-flow nasal cannulation. This is better used in the room with the negative pressure. If the PEEP ratio is around 200 to 300, we choose the high-flow. Set the flow rate at 40 to 50 L per minute, 100% oxygen for two hours, and then evaluate if this works based on the DOCS score. DOCS score is calculated based on the respiratory rate, saturation, and the FL02. If the DOCS score is more than 3.8, continue high-flow. If less than 2.8, stop high-flow, and then go to the non-invasive or innovation. If the volume between the range, continue for other two hours, and then re-evaluate. If PEEP ratio around 150 to 200, start non-invasive ventilation. However, bypass may worsen the lung injury because the high respiratory rates and tight volume will increase transpulmonary or driving pressure, worsen lung injury and pulmonary edema, and eventually induce pulmonary fibrosis. So initially, we set IPAP 12, EPAP 5 to 8, 80 to 80 to 100% oxygen for two hours, and follow the tight volume. If the tight volume less than 9, continue. If more than 12, intubate. If the PEEP ratio less than 150, intubate the patients. First, we need to test if recruitment maneuver is available. Set the highest PEEP around 20. If not, and the drug ratio more than 15, then paralyze the patient with ground position. Also, we follow the lung compliance. If the PEEP level still less than 50, and the oxygen more than 60%, and also the protein pressure more than 35, also complicated with the acidosis and the high level of the carbon dioxide, go to ECMO. Here, I share a case with you. This is the 64-year-old female transferred to our ICU from outside hospital due to the severe dyspnea and tachycardia. She was diagnosed with COVID-19 outside hospital, and she's healthy previously. The treatment in outside hospital, including the five days antiviral medication and antibiotics, seven days of corticosteroids. She also received nine days of the non-invasive ventilation. So this is the detailed treatment for the non-invasive ventilation in the last nine days she received. As you see, in the last nine days, her respiration become faster and faster. Her circulation become lower and lower. Her pressure set become higher and higher. The viral sign at the ICU admission, she was tachycardia 130, heart rate. She was dyspnea, the rate around 46. She was hypothermia, circulation only 82%. Blood pressure normal. We give her non-invasive ventilation with 100% oxygen immediately and prepare for the intubation. The blood gas, we got she was acidosis. The carbon dioxide retention, hypothermia, PO2 only 49 with 100% of oxygen. She was intubated with the low tidal volume and five centimeter of PEEP with 90% of oxygen. And also we tried the lung improvement maneuver. It is seen it doesn't work. And also her driving pressure is higher. It's around almost 20. So we paralyzed her subsequently. Also with the prong position ventilation for 12 hours. Unfortunately, her condition not improved. The PEEP still going down less than 50. And also complicated with the hypercapnia and her blood pressure going down, requiring the vasopressors. So then we consider to switch to the VIVI-ECMO for her. So this is the result from the echo we did for her. So actually you see the echo. She developed the echo called pulmonary. So this is induced by the severe hypothermia and severe pulmonary hypertension, not induced by the pulmonary embolism. And as the chest CD not available in the ICU, we routinely used the bedside echo to monitor the patients with the lung function as well as with the cardiac function. So this is the echo we did 10 hours after ECMO. And you see her condition improved with the adequate oxygenation. And also her vasopressors initially from 1 micro per kilo per minute going down to the 0.3. So actually all this indicated her echo called pulmonary was induced by the severe hypothermia, not induced by the pulmonary embolism. So this is the detailed parameters set for the ECMO for this patient. As you see from day 1 to day 9 during the ECMO treatment, you see the sweep rate and also the FL2, the flow rate decreased gradually. So her condition gradually improved with the ECMO. So on day 10, she went from the ECMO and was switched to the mechanical ventilation. So because her lung actually is not good, so still continue to use the pulmonary ventilation. And as you can see, her lung compliance from day 10 to day 14, the compliance improved with the pulmonary ventilation. And also her FL2 decreased from 50% to 30%. And now we are considering to win over the mechanical ventilation for her. But we're concerned about another issue. Her driving pressure actually increased. We are balanced about that. We are determined to win over the ventilation, the mechanical ventilation today. So here, the lessons we learned from this patient. So I emphasize we need to evaluate the mode and the parameter frequently. And they need to change, if not appropriate, this patient receiving almost nine days of the non-invasive ventilation. And actually her condition became worse during that time. So if we change the ventilation support earlier, probably the outcome would be better. And also prevent the acute pulmonary induced by the severe hypothermia. So this patient, after intubation, her blood pressure going down, repelling the vasopressors, and even the high dose of the vasopressors. So we consider this induced by the severe hypothermia and pulmonary hypertension. So this is very important. So we need to improve the hypothermia earlier. So here is the flow chart for the ventilation supports for the COVID-19 patients. We summarized for our patients. And based on the P-ratio, we choose initially the different modes of the ventilation supports. But we need to follow the changes based on the patient condition. If it's not good, we need to switch to another mode. This is very important for the patients. In the last, I will briefly talk about the outcome of the patients with the COVID-19 in our ICU. Here is the overall ICU mortality rate. It's around 30%. So actually, in the recent one month, more than 50 patients admitted in our ICU. And most of them transferred from other hospitals. And they are relatively sick. And the majority of the patients needed intubation. And some of them switched to the ECMO. We also followed the dynamic changes using some parameters of the survivors and non-survivors in our ICU. And you can see the non-survivors had persistent elevated carbon dioxide compared to the non-survivors. And also continuously elevated the non-injury score and persistent faster heart rates and relatively high dose of the muscular relaxants and higher dose of the vessel pressures. We also compared the survivors from ECMO and the non-survivors from ECMO. And also, we found that the survivors with relatively lower carbon dioxide compared to the non-survivors. We also run the unit and the multi-variable analysis for the ICU mortality. Due to the small size of the samples, there's no significant differences for these variables. But here, we found that non-compromised properly predict the outcome. That's the relatively better variables for the ICU mortality. Here, I summarize what I talked today. So the preparation for the outbreak of COVID-19 is important, as medical resources are always limited. Clinical ER patients tend to be older with comorbidities and laboratory abnormalities. Tightening both parameters of the ventilation supports with non-protective approach is crucial. The most common complication was ARDS, arrhythmia, and septic shock. Nearly half of the clinical ER patients needed invasive ventilation. The non-compliance made initially and persistently and with the carbon dioxide predict poor outcome. Thank you for your attention. Once again, thank you for inviting me. I'm happy to take any questions. Thank you to Dr. Peng and to the audience for attending. Again, this webcast is being recorded. The recording will be available to registrants within 24 to 48 hours. All questions asked via the question box will be answered offline and posted on the SCCM COVID-19 resources web page. To access the recording and answers to the attendee questions, please visit covid19.sccm.org slash webcast. To register for additional COVID-19 related webcasts, visit sccm.org slash disaster. And visit covid19.sccm.org for more COVID-19 information and resources that are being added frequently. Thank you. This concludes our presentation for today.

COVID-19 outbreak

ICU beds

personal protection

ventilation support

ICU admission

ICU mortality rate