A family member mentioned this yesterday. I'm interested to hear what our resident doctors think.

Following

Here's a longer take of his video with feedback from others.

https://thinkingcriticalcare.com/

HFNC not recommended for purely "hypoxic" pts due to aerosolization risks. The O2 helmets not widely available. So what else besides ETT/MV ?

That article mentions ECMO. Anybody have experience with it in these folks? I can't get a damn CT scan on them much less a trip to OR for huge ECMO VV lines. Limited resources and excessive exposures.

I was wondering this as well.....as it seems those that go on ventilators typically don't get off of them. they just have a prolonged life.

something to consider

There is a good article describing the phenotypes and recommendations in today's Medscape email blast. They reference the NYC Twitter doc, but the article refers to a German group and an article just published in a pulmonary journal. They make the case that these patients often behave differently than typical ARDS patients. They have hypoxemia with preserved lung volumes and that high PEEP is possibly damaging the lungs. As a urologist, I don't have the experience to judge this, but it is important to know that some experts in the field believe that. I can forward you the email if you like. Just PM me.

Good thoughts. I had a COVID ARDS survive with 100% oxymixer for ten days. Avoided the vent. I think we are all trying to avoid ETT/MV but the removal of BIPAP on these pts is a blow.

Keegan99 said:

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This harkens back to a hypothesis I read about that the virus was hijacking red blood cells, killing their ability to carry O2 and resulting in increased ferritin.

Edit: Found it.

Evidently this was an in silica modeling, I think?

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So if this is the case are they trying blood transfusions to help those patients?

Pulmcrit_ag said:

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I don't think that is the case. HFNC not only oxygenates but it decreases the work of breathing, particularly as you move into the 40-60 lpm range. I have kept multiple people off the vent that otherwise would be vented with the 6 lpm and intubate rule.

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Like I said, you two would know better than me. I've only seen three of these patients on HFNC and all three ended up intubated, but my sample size is so small that my observation is probably entirely irrelevant.

I think you need to institute HFNC early, what you are describing with the patient already in extremis is surely not going to be salvaged by it.

Can someone explain why high A1C and blood sugar is a big risk factor?

My doc has been "monitoring" my A1C. I've never passed 7.0 but float around 6-6.5 Now I'm a bit concerned.

Meh, don't worry. Your attitude will decide your fate

Player To Be Named Later said:

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Can someone explain why high A1C and blood sugar is a big risk factor?

My doc has been "monitoring" my A1C. I've never passed 7.0 but float around 6-6.5 Now I'm a bit concerned.

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A1C can be a contributor to less oxygen in the blood but I would think it would have to be higher than that and for a longer period of time.

I've read into this because my father and FIL have moderately to poorly managed T2 diabetes. It seems like it just comes down to having a poor immune system and immune response.

Player To Be Named Later said:

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Can someone explain why high A1C and blood sugar is a big risk factor?

My doc has been "monitoring" my A1C. I've never passed 7.0 but float around 6-6.5 Now I'm a bit concerned.

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Theory is you have fewer fresh RBC to carry O2.

Difference between 6 and 7 is nothing. There still seems scant evidence that a decent Type1 A1C is a risk factor. IANAD.

This is from perspective of a type 1 following this news.

Interesting. This kind of solidified my feelings of symptoms. Initially it felt like it was all in my throat. I just couldn't catch my breath and coughing made it worse. Lungs issues came later. My Lungs haven't felt terrible, but I have just felt like I am not getting enough air.

Now I feel no symptoms, just exhausted. My lungs feel perfectly normal, but not getting enough air. My heart rate still spikes doing simple activities.

Pulmcrit_ag said:

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I am using high flow nasal cannula at this time in a number of patients. As above with surgical masks in place and in negative pressure room. I would like to get some type of bed isolation tent for high flow NC patients to be in as it would help with decreasing dispersion of aerosols and droplets making both our PPE and our decontamination more effective.

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Does something like that not already exist? If not I'm pretty sure there are some engineers who read this board who could put a working design together.

Quote:

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My Lungs haven't felt terrible, but I have just felt like I am not getting enough air.

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This was me in late Jan early Feb. I even cancelled a stress test because my breathing had not come back to normal. Was just noticing yesterday that my breathing was finally back to normal and I was not short of breath doing normal tasks anymore.

Marcus Aurelius said:

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HFNC not recommended for purely "hypoxic" pts due to aerosolization risks. The O2 helmets not widely available. So what else besides ETT/MV ?

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WHO currently recommends HFNO as a therapy for COVID-19 respiratory failure, as does the Italian Thoracic Society, the Respiratory Care Committee of the Chinese Thoracic Society, The Australian and New Zealand Intensive Care Society, and a joint statement from the German intensive care, anesthesia, and emergency medicine societies.

Simulated use of HFNO with surgical mask placed over it demonstrated lower aerosol dispersion than NC w/o a mask or other forms of oxygen delivery like venturi masks or simple masks. I think any therapy that potentially spares the use of a vent is a therapy that should be strongly considered, especially one with lower aerosolization risk like HFNO.

When we are looking at a 50-80% mortality for those that require intubation, I think we should be looking at trying to avoid reflexively intubating as much as we can. Proning these patients early when feasible, trying out HFNO for those with increased oxygen demands, practicing a bit of permissive hypoxemia as long as there is no evidence of significant end organ dysfunction. Obviously many of these patients will still end up requiring intubation, but any patient that never had to go on a vent that typically would have is a huge win especially if inundated with COVID cases.