Good morning, and good night, good evening, everybody. Hello, my friends from the States and in China, and today we'll have the our Sino- U.S. panel discussion on COVID-19, which will last about 90 minutes. I'm Dr. Bindu from Wuhan. I'm actually working in Beijing. I'm from the Medical Intensive Care Unit in Peking Uni Medical College Hospital in Beijing. I have been here in Wuhan for already more than two months, and today I'm happy to moderate the panel discussion with one of my colleagues, Dr. Jianfeng Xie from Zhongda Hospital, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing. Please, Dr. Xie, say hello to everyone. Hello, good morning, and good night, my friends. Yeah, so it's our pleasure to have all together five experts, two from the States and three from China, to talk about the COVID-19 for the coming 90 minutes, and it's my pleasure to welcome Dr. Craig Cooper-Smith, who is the past president of the Society of Critical Care Medicine, and who is also from the Emory University. So good morning, and good evening, good morning, and good evening, everybody. The current president of SCCM, Society of Critical Care Medicine, who is from UPenn. Dr. Kepler. Hello, Kepler. Who is Kepler? I'm afraid he's not online right now, but anyway. No, I saw he is online now. I saw his cell phone. Oh, really? Please say hello to everyone. Luis. Turn on your microphone. There we are. Hello? Yes, yes. Luis, this is Dubin speaking. Hello. Hello, Dubin. How are you? I'm quite fine. And please say hello to our audience. Hello to everyone. Good evening and good morning, like Craig. Yeah. Well, thanks. Thanks, Luis. And there are also three speakers, or three experts from mainland China. One is Dr. Guan, Dr. Xiang Dong Guan, who is the president of the Chinese Society of Critical Care Medicine. Dr. Guan. Hello. Good morning. Good evening. And the second one is Dr. Haibo Qiu from the Department of Critical Care Medicine, Zhongda Hospital, Nanjing. Dr. Qiu. Hello. Hello, everyone. I'm Haibo. We can't see you. Yeah, but yeah, it's a program. Yeah, that's okay. That's okay. And the third one is Dr. Zhiyong Peng from Wuhan. Hi. Dr. Peng. Hi. Hello. How are you? I'm happy to hear, I'm happy here to share my experience with you. Okay. Tonight, we'll first ask the five experts a few questions about COVID-19, about their preparation, about the diagnosis and treatment for the COVID-19. And then we'll spend the last 30 minutes for Q&A. And so the first question concerns the current status of the COVID-19 outbreak in the states. What is the current status, Dr. Kepler? Right. Intense preparation. There are some patients who are identified to have COVID-19 disease. There are many more who are unprotected. Like you, we had intense preparation for changing our process of delivering care, making sure that our health care workers are safe, and engaging in very intense mitigation strategies to decrease the rate at which virus is transmitted one person to another, and the rate at which people present to the hospital for care. So we are well behind you. You've been very successful. And we have learned a lot about how you handled this particular virus and disease to inform how we prepare and how we are currently managing the patients who have it. So, Dr. Kepler, you are suggesting that the states, the government of the United States are following the approach we are practicing in Wuhan in China, but not as the, you know, European countries do, right? I think that we have learned from everyone. You have certainly had the largest and the longest experience. So we've taken lessons from how you approached it very successfully. We've taken lessons from what has happened and is still going on in Europe. As you know, we are a global health care community. There is something to learn from everyone. But yours has been the longest standing. So we have perhaps learned the most from you. Well, thanks. The second question is, do you have any patients with COVID-19 in your hospital or in your intensive care unit? And how about the preparation to handle these patients in your ICU and your hospital? And how about you, Craig? So we have many patients already in our intensive care units, and we have many patients already in our hospitals. So our health care system has six different hospitals, and we have come up with a plan for cohorting COVID-19 patients in both ICUs and in specific floors. And so we are moving all of our patients who test positive to specific hospitals, to specific ICUs that will take only COVID patients and specific floors that will only take COVID patients. And we have a plan in place to scale this up as the epidemic gets worse. And we have every expectation that the epidemic will get worse to move from our first two COVID ICUs to multiple ICUs and multiple floors where we can cohort COVID-only patients. But, Craig, how large will the intensive care, I mean, intensive care capacity, would you expect in your hospital? I mean, at work. So in Emory HealthCare, we will end up having the capacity to ventilate 500 patients without using split ventilation. So we have between our ventilators on hand and stockpile ventilators and older ventilators. And if we need to use anesthesia machines, we will be able to ventilate 500 patients. And then, so. Oh, sorry. And then if we need to do more, Lou has expertise, more than I do, on split ventilation. And so we can, if we needed to in desperate times, ventilate more than 500 people. Sure, sure. And how about the human resources? Do we have enough doctors and nurses who can handle the ventilator? So as of today, we have enough. As the number of patients grow, it's going to get more challenging because we're going to start having to take care of patients, not just in our 300 ICU beds, but outside of the intensive care unit. And there's an expectation that some providers will end up getting sick. And so we're going to be pulling resources from other places. We've canceled all elective surgeries. And so anesthesiologists and surgeons can help us. People who can work in the outpatient clinic, which are canceled, can come to work in the hospital. And people who work in the hospital can come to work in the intensive care unit. And so we won't have enough ICU providers, but by leveraging people who typically do other things but are comfortable and have spent time in the intensive care unit or time in the operating room, we will be able to increase our workforce fairly significantly. And when that is not enough, we're going to change our ratios using guidance from the Society of Critical Care Medicine. We will leverage our providers. So instead of, we have clearly different models between the United States and China. But instead of one attending ICU physician taking care of 20 patients, perhaps they'll take care of 80 patients and there'll be a tiered system in order to take care of everybody. Thanks, Craig. And I think the next question is for you too, Luis and Craig. Do you believe that the capacity, capability of testing in the States is adequate or inadequate right now? Lou, do you want to take that or do you want me to take that? Well, I mean, both of you. So I'll start. Okay. We are in transition. I think you are exactly right. If you asked this question a week ago, I'd say we won't have enough. I think that that was very plain for everyone. The very rapid expansion of locally derived rapid turnaround testing has been stood up at hospitals, including the University of Pennsylvania. There are many across the country. Now we have many, many more tests. The federal government has pushed out lots of additional testing that will support, besides the local tests, CDC-based testing. So we are rapidly catching up. I think that it would be ideal to be able to test everyone where we have any suspicion, but right now we have more selective testing as the number of available tests increases. Craig, what would you add to that? I don't have a lot to add. It's exactly right. When we started, we did not have enough tests. Right now we can test our ICU patients. We can test our floor patients. We can test our healthcare workers. And we are increasing capacity day by day to fairly shortly be able to test everybody who needs a test, whether they are at home or wherever they are. So increasing day by day. But we can clearly test our hospitalized patients now. How long can you get the result? Our local test is six hours. Our local test is also six hours. Six hours? Our local test. So initially it was longer, but the local tests are all coming back in about six hours. So what kind of patients will receive the test? These are the same kinds of patients that everyone worries about. The person that has a fever, has symptoms, that has no other explanation for their presentation that is respiratory in nature, may have traveled, may have had an appropriate contact. I think that there is a desire to have a liberal application because of the variability in presentation of patients with COVID-19 associated. So we are on the side of caution. So I think there's a lot of flu A or flu B patients. So what's the proportion of the positive test? We're seeing co-infections with flu and COVID-19. And certainly in the United States, on the West Coast, in Seattle and California, they're seeing patients who are co-infected. And we're seeing a lot of flu A and flu B patients. They're seeing patients who are co-infected. And so it used to be that we said if somebody had flu or bacterial pneumonia, we were stopping. But because we are seeing co-infection, even upon arrival of patients with flu, if somebody has respiratory failure, somebody has symptoms, cough, shortness of breath, fever in half the cases, et cetera, we're testing even if they have the flu. So we're looking for co-infection. Okay, thanks, Grant. And the next question goes to Luis. And can you describe how the SCCM supports members during the outbreak? There's a lot that SCCM has done. It's for members and non-members. We have created a whole host of open access communications, as well as resources to help educate the people that would be stood up to help normally in the ICU. Those are all free. We have created a report on ventilator availability, as well as ICU bed community, and presented a tiered staffing model. This way, your hospital does not need to articulate their own tiered staffing model. We have a template for everyone to use. Today, we will be standing up a COVID-19 listserv that will be moderated by our immediate past president, Heather Bailey. We have a host of media offerings all throughout the country. We've ended up on all kinds of national news. Craig has been featured prominently in many. We have had the opportunity to interface with many different aspects of the administration, even including the president and the vice president earlier this week. We sent out a survey for bed capacity and COVID-19 patients using our academic leaders in critical care medicine group. And there is a discovery research network project specifically focusing on COVID-19 disease that will help to inform members and non-members about best practices, prevalences, and a host of other aspects that are important in helping guide care. We've been very, very hard at work supporting the members and non-members because all of this goes out to everyone. You don't have to have a membership to access it. Well, thanks, Luis. And I believe the next few questions goes to our Chinese colleagues. And the first one is, how about the Chinese Society of Critical Care Medicine and what's this plan and what's this effort in supporting its members to fight against the COVID-19 outbreak? Please, Dr. Wang. Oh, okay. As soon as the coronavirus outbreak started, Dr. Qiu Huaibo and Dr. Du Bing joined the expert panel of the National Health Commission and arrived at Wuhan at the very first time, just before the Chinese New Year. Based on several observations and the investigation, they realized that the situation was much more severe than they were. And the number we are climbing, the patient number we are climbing, and there are especially critical ills among them. So, on January the 29th, the three main Chinese critical care societies, as you know, we have three societies in China. We have three societies, including the Chinese Society of Critical Care Medicine, Chinese Association of Critical Care Physicians, Specialty Committee of Critical Care Medicine, and Chinese Association of Pathophysiology. We made a proposal advocating that all of the Chinese critical care staff should dedicate themselves to fight against the coronavirus at the frontline, at Wuhan, to try to do their best to rescue patients, rescue critical patients suffering from the disease. On February the 2nd, I left Guangzhou for Wuhan to support the work as a member of the national expert panel. I traveled to Wuhan, Hubei, not only limited to Wuhan, and also to Hubei, almost most cities, to discuss the disease control and supervise the clinical treatment of severe NCP patients. I was deeply impressed that in less than half a month, the Chinese critical care staff quickly responded to society's calls made by our societies. And more than 15,000 doctors and nurses and staff specialized in critical care arrived at Hubei province, at Wuhan, making one third of total medical workers dispatched outside Hubei. As the leaders of Chinese critical care societies, we are so proud of our colleagues, our staffs at critical care medicine. In the first five editions of National Recommendations of Diagnosis and Management of COVID-19, few contents were related to strategies of dealing with critical conditions. Since the critical care experts joined the discussion of the sixth edition guideline recommendations concerning critical cases started to be involved. Detailed contents include intubation and mechanical ventilation, lung recruitment and proliferation, glucocorticoid and antivirus therapy, convalescent plasma, continuous CRT, nutrition support, and so on. Moreover, the Chinese critical care societies had also published a guideline focusing on severe COVID-19 management. We are looking forward to further discussion and closer cooperation with SCCM. During the outbreak of COVID-19, the Chinese critical care societies had made good use of internet access. The societies prompted webcasts and net meetings almost three to five times per week to provide techniques, to talk about techniques and valuable experience from the front line to all the medical workers throughout the country and even worldwide. The Chinese critical care societies have also made good use of the internet to communicate with the European doctors, with the U.S. doctors. And finally, experts of critical care medicine have accepted the numbers of interviews by TV program government to educate the general public about COVID-19, especially the knowledge of severe cases. In this way, they explained the most concerns of public and removed doubts and fears. That's all I want to say. Thank you very much. Thank you. Well, thanks, Dr. Guan. And the next question goes to Dr. Zhiling Peng. We know that a small proportion of patients with COVID-19 had the need for surgical procedures. Do you know, as you are local from Wuhan, do you know any specific preparation or measurements that have been taken in the operating theater for this patient? And how about the operation? Please, Dr. Peng. Okay. Thank you for your question. So, actually, in my hospital, we have performed almost 80 cases, surgical cases already since the outbreak. And we prepared an operation room equipped with the negative pressure. And we also have the different protocols for the precaution of the droplet and precaution of the air ball. So, based on the procedure. So, if the surgery, we need to intubate the patients. And, of course, we need to prepare for the precaution of the air ball. So, just depends on the procedures. But most of the procedure, they need to intubate the patients. So, most of the time, they prepare for the air ball precaution, air ball PPE. So, after the surgery, we also need to clean the environment of the OR. And we disinfect the air with some disinfectant, just spray the disinfectant in the air. And also, we clean the surface of the equipment by wiping the surface using the disinfectant containing chloride. So, we cleaned the OR, the room. But because this OR equipped with the negative pressure, so we are confident about that. So, everything is okay. So, so far, nobody infected in the OR. Okay, thank you, Dr. Peng. And I'll handle the next few questions to my colleague, Dr. Xie. Dr. Xie, please. Yeah, so the next question is also for Dr. Peng. So, how are you addressing the portable X-ray device in terms of mobile LEDs throughout the rest of the hospital? So, are you cleaning them after each patient room contacted differently than before? So, actually, so you are, you know, in China, all the patients are put in the big room, so not in the individual room. So, when we perform the procedure, I just clean the surface of the, of course, we need to change the pattern used for the patient, specific pattern for each patient. And also, we just clean the surface of the machine. So, that's it. So, nothing special. Okay, thanks. So, do you move all the POC testing in the, in the room so that the lab does not need to travel the specimens? So, so if not, what do you think? No, no, we only do some, you know, for the, you know, for the ABT. ABT, yeah. But most of the samples, we send it to the central lab. And we have a specific team who is responsible for carrying the samples each time. And they are well equipped with the PPE. And also they carry the bag, the bag also with the biological safety equipment. So, make sure they all, all the process safe. Yeah, just as we did for the, for the sample. So, do you think if it is ideal if all of the POC testing is moving to the room? If possible, it should be good. Yeah. So if we have enough advice, we can do that. Well, I don't think so. I don't think so. Because we, apart from the ABG, we have the chemistry, we have the, you know, complete blood count, we have the cultures, we have all the other, I mean complicated laboratory tests, which cannot be done. So, I would say that ABG for POCT is okay. Blood glucose for POCT is okay, but not anymore. Yeah, yeah, you're right, because we should prepare the special equipment for other, for other tests, especially for the culture. Yeah, for the culture. We have, we haven't, you know, the little room, the little space in the ICU. Okay, thanks. So the next question about infection control is, how are you handling room trash and waste? Wow, this is the, depends, depends. So if the, if the, if the waste, if the trash from the patients, and we have a special hallway, a special load for this kind of waste, and also we put it in the back, you know, double bags. And then we also, you know, use the specific elevators, specific hole to carry this garbage. But yeah, this is only for the waste from the patients, but others, I mean, it's the same as we did in the loading practice. So another question is, you know, some patients were not very severe and they remained able to eat the foods. So how can we send the food to these patients? So also, we have, because the food is clean, total clean, and the food we take in from the clean area to the patients. Is there any special passenger gate and you can pass the food into the room? Yeah. Yeah. Okay. So the next question is for Dr. Du. So what are your thoughts regarding the HFNCO2 and the viral particles? Well it's very difficult. I think this is a controversial issue that no one has the answer yet. But anyway, according to our observation, Dr. Xie, that we all agree that the failure rates of high flow nasal cannula in patients with COVID-19 is quite high. It's either, I mean, persistent hypoxemia or defined as the, you know, respiratory distress whenever a patient was treated with high frequency nasal cannula. Whenever this is the case, I do believe that you may consider the possibility of endotracheal intubation and invasive mechanical ventilation right away. And probably some of my colleagues will consider the, you know, non-invasive mechanical ventilation instead. But anyway, in my opinion, that high frequency nasal cannula and the non-invasive mechanical ventilation are some sort of, you know, equivalent during treatment of the patient with COVID-19 because both of these have a higher failure rate. Yes. Thanks, Dr. Xie. So the next question is from Dr. Kaplan. So the question is, are staff allowed to go home after the end of their shift or are they just staying in the hospital or nearby site? So in China, I know the doctors and the nurse or medical staffs were allowed to go home. However, most of them will not, would like to go home, just as they would like to stay in a hotel or in the hospital, in a hotel nearby the, near the hospital. They will, they think that they may be infected the families, so they will stay in the hotel nearby the hospitals. But how about the states, Craig and Luis? Almost all of our providers are going home. A few of them are choosing to self-quarantine, but we are making the point that COVID-19 is present throughout the community and one can get COVID-19 not just in the hospital, but one can get COVID-19 by going to the grocery store when somebody who's asymptomatic or minimally symptomatic, relatively close to you has sneezed or coughed. And so this is not something which is present only in the hospital, it's present throughout the community. And so our providers are going home. We're practicing good hand hygiene at home. We're practicing social distancing, so we're not going to restaurants and we're not going to concerts or movie theaters, but we are sending our providers home with the understanding that you can get COVID-19 easily at the grocery store, just like you could get it in the hospital. Luke? And any comments from Luke? It's important that wherever you are in the world, everyone has very similar concerns and you're doing exactly what Craig is doing. We are telling people to go home and use good hand hygiene and practice social distancing. Thanks, Luis. Thank you. So let's move to the question for diagnosis. So the next question is also for Dr. Du. So what is the characteristics of critical ill patients and what's the difference between the critical ill of the COVID-19 patients from other SARS or flu A or flu B pneumonia? Well, I would say that it's not a question about diagnosis. The difference between SARS, COVID-19 and influenza pneumonia, because I would say that we define the critical ill patients with COVID-19 as those who have the evidence of hypoglycemia and at least in my mind, the major difference, I would say the similarities between COVID-19 and SARS is one, they share the same name of the coronavirus. Second, the respiratory failure is the most common organ failure that we encountered in patients in both the COVID-19 and SARS. The major difference between the two is that it seems to me that a patient with COVID-19 had more organ failures, especially at the early stage of the disease course. For example, the cardiac injury has manifested at the elevated level of cardiac injury biomarkers, such as hypersensitive cardiac trouble in the eye and also in some patients of the BMP level. And next, the acute kidney injury or acute renal failure requiring the CRRT has been observed in about 20 to 30 patients in critical ill patients with COVID-19, but however, which is rarely seen, if any, in patients with SARS. And about the other clinical features, such as the capability of human to human transmission, I think it's the expertise of the ID specialist rather than intensive care. But anyway, according to my colleagues in infectious diseases, it seems to me that COVID-19 is more prone for human to human transmission than SARS. Yes. Second, starting to. So the same question for Craig. So how can you, because you have 50 to 20 critical ill patients, so what's the criteria for ICU admission for these patients? And is there any definition for the critical ill patients with COVID-19? So the criteria for admission to the intensive care unit is the same criteria for admission to the intensive care unit as any other critically ill patients. So there's no distinction. If you're hypoxemic and you need the ICU, you're hypoxemic and you need the ICU. So the criteria for admission are the same, but we have sort of three categories, if you will. Somebody we know is COVID positive and we send them to a COVID ICU, somebody who is in the intensive care unit for an entirely unrelated thing, a stroke, a heart attack. And they're just, they had a major stroke and they come to the ICU. But then we have a large categories of people, the persons under investigation or PUI, people who come in with a story that's consistent with COVID-19, but also consistent with the flu and also consistent with metanouma virus and many other things that are coming this time of year. So somebody comes in with a cough, maybe a fever, worsening shortness of breath and hypoxemia. And so we admit them to the intensive care units and we test them and fairly rapidly, we have an answer. Hopefully within six hours, we find out whether that patient is COVID positive or COVID negative. If they're COVID positive, they're cohorted with other COVID positive patients. And if they're COVID negative, then it's like anybody else. We treat them the same. The ventilators are the same. The proning is the same. The paradigm is the same. The only difference really to start with is knowing about the protective equipment that we need for our staff, because we'll treat somebody who's viral negative differently than we'll treat somebody who's COVID positive in terms of protecting the staff and PPE. But the critical care and the admission to the critical care is identical. Okay. Thanks. Thanks. So how do you think is the difference between the COVID-19 and other common pneumonia? Is there any something special for the COVID-19? Is that for me? Yeah. Yeah. So the difference that has been seen around the world, that's perhaps difference is the much higher incidence of the cardiomyopathy. And so patients have hypoxemic respiratory failure. It's not common for patients with hypoxemic respiratory failure to all of a sudden develop an ejection fraction of 10% and go into a VTAC or V-fibroacystolic arrest. So that's different. So ARDS in all forms is ARDS. The hypoxemia we're seeing in COVID-19 is exactly the same hypoxemia we're seeing in ARDS of other sources. And Dr. Dubin just spoke about the need for CRRT, and we're seeing CRRT in a certain percentage of cases. What appears to be different about COVID-19 in the worldwide experience is the cardiomyopathy. Because the patients, a significant number of patients, their ejection fractions go from normal to almost nothing, and they're having cardiac arrest. And that's not common in the other viral pneumonias or ARDS that we're seeing. Right. Right. Thank you. Okay. Dr. Hsieh, I'll take the next few questions. Can I? Okay. And the next question, I think, will go to Dr. Chiu. And how do you think about the timing indication about the invasive mechanical ventilation as well as the, how, would you please comment on the long protective mechanical ventilation strategy? Please. Okay. Wait. Okay. Yeah. Hello, everyone. I think for the timing of incubation and mechanical ventilation, I do believe it should be seen as a routine practice. But we know this pandemic, during this pandemic, it caused critical care resource limitation. And also some reason, other reason, the most of the patient, most of the critically patient with COVID-19, most of they received the high flow oxygen therapy. And then if the patient does not tolerance the high flow nasal cannula, and then transferred to the NIV, and then if the NIV does not work, then the patient receive the intubated and the mechanical ventilation. So our data show, and I have a little bit different comments with Dr. Craig, the difference in his opinion, because this kind of patient, the duration from the initial symptom to the respiratory failure in most of the patient is longer than seven days. That to say, many, many patient go on to develop the respiratory failure, go on to failure, mostly after the onset of the illness, seven to 10 days. And also, many, many patient with the illness, with hypoxemia, with severe hypoxemia, does not have the sign of respiratory distress, does not have the tachycardia. So the hypoxemia without most of the hypoxemia, sometimes of the hypoxemia does not have the sign or symptom. So we call the hypoxemia is silent hypoxemia. So that to say that for this kind of patients, so many patient did not, we don't, for the physician, if they don't notice the hypoxemia, the oxygen therapy could be delayed. And also, if the patient receives the NIV or high flow, if the SpO2 is okay, is higher than 93%, most of the time, most of the physicians think it's okay. But you know, many, many patients, the SpO2 is okay, but the respiratory rate is by higher than 30 or 35. And some patients with the very huge inspiratory efforts. So for that kind of patient, because the SpO2 sounds good. So the incubation most time is delayed and the mechanical ventilation is delayed. So I think for the COVID-19 patients, severe case, if the SpO2 less than 93% or mostly FO2 is 80% or 100%, that to say if the pressure less than 100% or tidal volumes are higher than 8 or 10 milliliter per kilogram, or if the patient has a huge inspiratory efforts or respiratory rate more than 30 or 35, and during the NIV and high flow, this time, I think this patient should receive the intubation and the mechanical ventilation. So from the guideline of the Chinese Ministry of Health and also from the guideline from the WHO also shows that the duration of the NIV should not be longer than two hours. But in China, most of the time, the critical air patient receives the NIV or the high flow longer than five days or one week. I think the lesson should be noticed, should be learned from Wuhan. And also for the ECMO, most of the time, the ECMO is already very late. I think as usual, if the patient after the mechanical ventilation, after the non-protective ventilation, after the do the crown position, if the PF ratio less than 50, longer than 3 or the PF ratio less than 80, longer than 6 or the FO2 100 and the PF ratio less than 100, and as for example, the PCO2 higher than 60, longer than 6 or this kind of patient should be, ECMO should be considered. But in Wuhan and in also most cases, the ECMO, most time, the timing of ECMO, most time is delayed. Another item is the protective ventilation. We know the low tidal volume, low tidal volume is the basic for the protective ventilation. So most timely, we set the tidal volume of 6 microgram per kilogram, ideal body weight. And then see the plateau pressure and the driving pressure. If the driving pressure less than, plateau pressure less than 30 or 35 centimeter water or the driving pressure less than 15, that's okay. If higher than that value, the tidal volume should be reduced, reduced. And then the PIV sighting is very interesting, very interesting. We noticed that the FIO2 PIV sight, if you use the FIO2 PIV table to set the PIV level, mostly the PIV level is very high and the plateau pressure is very high. For example, the patient need 100% FIO2, but the PIV should be set 18. 18 centimeter water. But if the PIV is at this level, the plateau pressure could be 40 or 50. It's too high, it's too high. So, for this kind of patient, we noticed that we should use the compliance or oxygenation guide PIV sighting. That to say, we just decided the PIV level, after the recruitment manual, we set the PIV level 20 and then decrease the PIV to 15, 10 and 5. And also we observed the plateau pressure. That to say, we could evaluate the compliance. When the compliance is better, the PIV level is better. So, the COVID-19, the patient with COVID-19 is a little bit different with H1. Patients with H1 will have a higher RDS. And also, after the PIV sighting, and then mostly we use the pump position. Most of the patients, most of the severe cases, pump position is work. Oxygenation, PIV pressure could be improved. But some patients, PIV pressure could maybe drop down. For this kind of patient, we do recruit manual. Most of the patients had a good response. If no response, we keep the patient in the supine position. That's okay. That's all. Well, thanks, Dr. Qiu. I think Dr. Qiu pointed out the importance of non-protective mechanical ventilation in patients with COVID-19. In saying that in patients who failed the NIV trial, and the high-flow nasal cannula trial, and we should consider prompt endotracheal intubation, and lower tidal volume as 6 mL per kilo, predict the body weight, and we should carefully adjust or set the PIV level according to compliance or oxygenation. And in these patients, pump positioning seems to work in at least majority of the patients, and especially in the early phase, and it seems to me that the recruit maneuver also works in improving the arterial oxygenation, right? Yeah, thanks, Dr. Qiu. And the next question I'm concerned about the efficacy of antiviral agents. And I think this is a question to all the panelists. How would you consider the use of the antiviral agents in patients with COVID-19? Any comments from the panelists? Actually, there are two types of antiviral medications on the trial now. And just based on the publication, just published two days ago, about the Lopinavir, based on the RCT result, actually Lopinavir doesn't work well for the COVID-19. But they just point that if the Lopinavir given earlier, probably different result. So this is for the publication from the Lopinavir. The other is about the Remdesivir. Remdesivir actually we haven't got the result yet. But I heard the story, probably Remdesivir probably work for the COVID-19. So this is why the FDA approved the Remdesivir for the COVID-19 already in the States. So my question for Dr. Peng, is that I know there are two trials on Remdesivir in patients with COVID-19. One is in mild cases. One is in the moderate to severe cases. So if you heard anything about this, about the preliminary results, so does it work in the mild cases? Or does it work in the severe cases? So from the talk, this is from the talk, so I haven't seen the result yet. But someone told me. So probably it works, both the mild cases and the severe cases. But I don't know the result yet. Okay, sure, I know. We all know that there is an ongoing, there are ongoing two trials, two ongoing trials that are still in process in recruiting more patients. So we need to still wait for quite a long time and to see the results, if any. But anyway, the recent paper published online in the New England Journal of Medicine about Galitra, the Lopinavir and Ritonavir, had a negative results in primary endpoints, although the modified ITT, you know, analysis, intention to treat analysis, showed a trend towards improved mortality rates in patients treated with Lopinavir and Ritonavir. But anyway, I do believe some of the experts or post some critics on the so-called modified ITT analysis. Yes. And for Lewis and Craig, how about the chloroquine? And I know that there are some, you know, you know, interests in this phase about chloroquine. And is this surprising, right? It at least makes mechanistic sense to use chloroquine. But I don't yet have any data that says there's an outcome advantage, even though it is intuitively attractive to try and leverage medications that work for other conditions that have related properties. So I don't know. Are you using chloroquine for patients that are COVID-19 positive at Emory? We are not. I'm telling people to use it in the context of a trial. And I want to get back for a second to the comment made just about Remdesivir a second ago. It is not FDA approved in the United States for COVID-19. There are no FDA approved substances for COVID-19. We're actually part of an NIH funded trial on Remdesivir. And we hope to have those results relatively soon because unfortunately the more cases we see, the more patients we're able to enroll. But there are no FDA approved agents right now. All the agents that are being discussed, while they might make biological sense, my personal belief is that they should all be studied within the context of a trial because there are many agents in many critical care diseases that make biological sense, a few of which are helpful, many of which don't do anything, and some of which are harmful. Well, thanks, Louis and Craig. And my personal impression is that there are no effective antiviral at this at the current stage so I was I would not use any antiviral out of the context of clinical trial in my patients was COVID-19 because none of them had solid confidence solid evidence that's you know convincing me to use it in clinical practice. I agree. You agree? I agree too. I agree. Okay okay thanks Dr. Wang. Any comments from Dr. Qiu? Yeah I don't think that now the antiviral drug is effective so we I like to wait the clinical trials the result of the clinical trial so and you know in China in Wuhan and in China we try several drugs for the for the patients with COVID-19 but we don't observe we we don't I have no idea about the efficiency but we observe the minus side effect of the drugs. Okay. Okay thanks Dr. Qiu and the next question is about the corticosteroids. Would you consider the use of corticosteroids in patients COVID-19 and if the answer is yes what do you think the about the indication the dose and the duration and it's again the question to all the panelists so please. No. Never a no. The answer is no from Craig. To be very bad. But I think for most patients with COVID-19 maybe it's no it's no but but for the some some patients very sick patients if there is the progress of the disease is very quick for example the inflammatory response is very bad and the chest accurate chest actually or CT is showed primary infiltrate is getting worse or the carefree drop down maybe many many physician in Wuhan would like the choice corticosteroids and or increase the dose or increase the duration duration so we could see many many many patient severe patient was used steroid was used in many many severe patient. Thanks Dr. Qiu. How about you, Luz? Okay so one paper published and probably next probably last week last week on the in the JAMA so indicated so you know they have a lot of the factors factors related to the mortality. One one main factor is that if the patient is using the steroids probably we are improved the mortality I mean but this is the retrospective study not the not the RCT just the one factor I mean it's but excuse me excuse me Dr. Kong yes this paper the results of this paper is contradictory to what we saw in previous publications which which suggests that the either non efficacy or increased you know mortality rates was the use of corticosteroids in viral pneumonia so this is is the first I at least in my mind this is the first paper published in peer-reviewed medical journals that's showing by univariate analysis showing the benefits of corticosteroids in patients with viral pneumonia so what's your comment so I mean so I mean it's the because this is the retrospective study so it's not the it's not the randomized study so it's the just the analysis in which we are related to the outcome but I mean the this still was only only one of the factor probably related to the outcome but it's but it's not RCT yeah okay but actually you know I also I also know the you know the review paper published the last last month about all the you know about the corticosteroids and all the virus pneumonia and it shows the you know the corticosteroids use wouldn't affect any outcome for the patients with the virus what virus pneumonia probably worsened the you know the you know the outcome so so you are saying Dr. Peng you are saying you will not consider use of any corticosteroids in patients COVID-19 right depends depends depends okay okay how political how political I mean occasionally just like Dr. Cho said if the situation deteriorated well it deteriorated rapidly I mean you know the p-ratio going down quickly and also the chest CT you know become worse rapidly and then I will try I will test the steroids corticosteroids okay yeah so how about you Luis please so rather than being political I'd like to be clinical some of the patients that we will take care of with COVID-19 disease will develop complications in the hospital some of those may lead to septic shock still in a patient with COVID-19 disease when that happens we have some around how we provide steroids as adjunct therapy to support adrenal gland function so in that contest steroids can be particularly helpful they've been outlined by the surviving sepsis campaign in that light so we will have a subset of patients or COVID-19 positive who receive steroids for related therapy not as primary pulmonary COVID-19 therapy and they represent a group for us to evaluate and determine whether or not there is any kind of a role in that unique patient population and I think that's an important point and and my my my no before was within the realm of outside of a clinical trial and so getting back to the the data that that was previously brought up the previous data on steroids and viral pneumonia and then SARS show at best no efficacy at worst increasing mortality and so I would not give it to somebody outside the realm of a clinical trial in light of our current knowledge at the same time there are data that suggests that steroids for sure get you off pressures quickly and potentially improve your mortality and septic shock if you have both of those at the same time if you have COVID-19 and a secondary infection we surely don't have good data on what to do then I'm very supportive of doing trials but I would not use them outside the context of a trial okay thanks thanks Louis and Craig for you you know very clear stated you know opinion but I I would say I am against the corticosteroids especially the long-term high dose corticosteroids in patients with COVID-19 or in general patients with viral pneumonia and because we all know that it's prolonged the viral setting it's you know make the lymphocytopenia even worse but currently I'm not quite sure about the efficacy and safety of short-term corticosteroids let's say three to five days I don't know I don't know it's beneficial or harmful you know yeah I understand the importance of clinical trial and I would love to see the results of the you know any trials any RCTs on you know in patients with viral pneumonia not only not necessarily COVID-19 yes and I think the Craig I think Dr. Guan had a specific question for you Dr. Guan yes Craig I want to talk about convalescent plasma as you know convalescent plasma is a specific therapy for viral infection now up now Wuhan has obtained sufficient convalescent plasma from covered volunteers the total amount of plasma about 200,000 milliliters more than 200,000 milliliters currently the convalescent plasma therapy has been widely promoted in clinical practice we observed that some patients met good response while others not however even if only 70 or 60 percent NCP patients we would benefit from convalescent plasma the therapy should be should be viable according to published studies concerning MERS COV antibody titers in the plasma should be determined before use but in Wuhan due to urgent and limited conditions the test antibody titers has not been set up yet so you do you have you have any idea about the convalescent plasma so my answer is going to be entirely theoretical you've used it we have not so in my mind like with remdesivir like with steroids like with anti-il6 like with multiple traditional Chinese medicines I think it's appropriate to study but I don't know that we have adequate data so because I don't have personal experience with it it's not saying no I believe that there could be a role because there's anecdotal experience just like we heard anecdotal experience with steroids just now and a little bit with remdesivir and we didn't talk about anti-il6 but there's a lot of people with anecdotal experience with that and we haven't talked about traditional Chinese medicines I'm going to pronounce it wrong but there's traditional Chinese medicines that have also been used and I believe that every one of them might play a role if we knew who the right patient population was but until then my personal bias would be to use it in the context of a study but again you have extensive experience with it and while we have a number of patients we haven't used it at all we're only about a week into the COVID-19 pandemic in the United States I just think at least the convalescent plasma is a specific method for COVID-19 no any antivirus drugs convalescent plasma is one of important drugs I don't think so I don't agree I don't share your opinion Dr. Guan theoretically we know that a convalescent plasma might be okay might be effective in patients with infectious diseases but paper published in Lancet shows that convalescent plasma from patients with influenza does not work does not work does not improve clinical outcome in patients with influenza so which suggests that theoretically effective therapy may not be true may not be true in clinical practice in you know real life so I agree with Greg that we should have some more solid evidence before we recommend this routine use in our patients COVID-19 is we never understand we still do not understand what is the indication what is the you know you know timing and how would you how would you you know evaluate its efficacy and safety as well so so theoretical professor yeah so I want to say one one sentence one sentence just one sentence at least convalescent plasma is hopeful for COVID-19 is that okay everything okay it's theoretically effective but only in the early stage only sure please Dr. Bong I'm I because I uh we tried two cases using the convalescent plasma for the patients so because the the this two pages you know they have the you know the you know from the the patient onset to the you know to the treatment almost more than one month so I don't think it's the even if it's the in the late stage of the disease this treatment probably probably doesn't work because it's too late for the for the you know for the patients so probably in the early stage I don't know maybe maybe have a better result another concern uh I will consider is the is any is any possibility you know the anybody will combine the you know the the virus and will induce the sarcoid storm yeah well sure I agree maybe maybe for the patients in the late stage I don't think the plasma will work so many just uh we however other things we think I think we can we can discuss because in the in the trial for the phase two and the phase three trial for the influenza the plasma was failed to improvement improve the outcome however the dose they used only two unit so if we increase the dose dosage maybe it can work maybe well it seems to me that maybe yeah theoretically maybe right correct we share the same opinion right so this is being recorded because dubin and I are old friends and I think this is the first time we've ever agreed so we're gonna let the whole world know that we're agreeing right now oh well uh as we are we we are having I think we we still have about 10 minutes to go but anyway this is a question about PPE about personal protection equipment I would like to see I would like to know what about the PPEs in the states for healthcare workers and in China what difference and so it's again it's a it's a question to all the panelists please personal protective equipment personal protective equipment please we are following in the United States the the CDC the Centers for Disease Control and Prevention guidelines for the management of patients and what that says in somebody who is going to have an aerosolizing procedure like intubation like intubate like inline suctioning we'll use an N95 mask we'll use eyewear protection be it either a face shield or goggles we'll use a gown and we'll use gloves and for patients who are not undergoing aerosolizing procedures we'll do everything the same except for instead of the N95 mask we'll use a surgical mask and so you're based upon I'm sorry go ahead please please no I was going to say based upon everything that I've seen on TV it looks like there's a different people in China are using different types of PPE but we're following based as we know more and more about the virus and how it's spread we're following the guidance of the CDC in the United States which says again ace N95 face shield gloves gown for aerosolized procedures and everything the same except change the N95 to a surgical mask if somebody's just in the ICU but it's not aerosolized but how about the uh the so-called positive pressure stuff when you intubate the patient so when we intubate the patient what I told you is is for patients who are at risk for aerosolizing and the highest risk would be somebody intubating that is exactly what our CDC what the federal government has told us so N95 face mask eye protection gown gloves and that's what we're following okay it's different from what we saw from the you know you know WHO recommendation how about you Luis Luis are still with us it seems to me that the Luis is not answering although he's still connected but anyway you know in China uh Greg you know in China is so Luis yes so and then that would be you can't effectively mask in which case especially for information that we do use a cap or an airflow device so that what we do is exactly well thanks Luis I think that in most of the hospitals in Wuhan and possibly in China that the health care workers are over protected partly due to reasons that they are over 3,000 health care workers who got infected with COVID-19 in the whole nation so the most common PPEs we saw in health care workers in working in the intensive care units includes but not limited to a hat and N95 face mask and possibly plus or minus a surgical mask which I don't think is necessary but anyway a google and face shield I would only use one but anyway some of my colleagues will use both and a coverall a coverall and two double gloves gloves yes I think some words you know over protected but anyway I do understand the rationality behind this so I think I think it's important as we talk about differences between the countries that the recommendations have evolved I'm not saying that what was done in one country or the other country is right or wrong but since since COVID-19 came to the United States again we're following federal guidelines we're not making Emory specific guidelines we're following what the United States government says and and they've changed the PPE recommendations have changed over time and we have changed with the recommendations so you mentioned for instance double gloving so our initial recommendations for high level PPE for impermeable gown and double gloving but as more data comes out that suggests it's aerosolizing that you don't need an impermeable gown you don't need double gloves I'm not saying that what you're doing is wrong I'm not saying that what we're doing is right but I will say that it is evolving and you had the most of your patients one or two months ago we're having our patients coming in right now and recommendations worldwide are evolving over time so I think we're both following what our governments say and as the World Health Organization evolves as this becomes a global pandemic it already is a global pandemic we should all follow guidelines as they evolve. Thanks. I think the audience also have another question concerning with the the so-called reinfection which means that the the some of the patients will have a a positive PCR test with regards to the SARS-CoV-2 and after you know 203 negative results so a re-emergence of a positive PCR test I'll take the question because personally I don't believe it's a reinfection it's it doesn't make any sense that the patient will got will get reinfected I mean after such a short period of time but it is true that we do have some patients not a very small number not a very small number of them but anyway we do have some patients who got a positive test after a series of negative tests I do not have any explanations for this the possible reasons for this phenomenon might include but not limited to the sampling technique might include the you know the manufacturers the test keys from different manufacturers and also might related to the effect which I do believe that the virus might or exist with human beings might reside in somewhere in the patient body for quite a long time so which you know I mean will manifested as the viral shedding from knowing that from time to time but I'm not quite sure whether this phenomenon was associated with the capability of human to human transmission I don't know because currently we have only one publication in JAMA as a research letter as a letter sorry to the editor to show that among the four patients only there are no signs or no evidence of of you know human to human transmission after re-emergence of the positive PCR test but we should keep an eye on what is going and what are how about the you know the other patients yes I think we are running out of time we are currently at the end of the panel discussion and I hope I don't know but I don't know how many audience we have in this panel discussion but I hope that the discussion among the the American colleagues and Chinese colleagues about COVID-19 will shed more light on what is going on in the States and what our experience I mean in China both the success and failures and hope it will help not only our American colleagues but also our Chinese colleagues in the future combat against the COVID-19 hopefully we I mean we can meet anywhere in the world after all these you know disasters come to an ending and I do hope that every one of us not only the panelists but also the all the audience who are present and who are absent and to have good luck thank you very much very good bye

COVID-19

panel discussion

experts

China

United States

outbreak

treatment strategies

antiviral agents

convalescent plasma

clinical trials

PPE

healthcare workers

guidelines