While some parts of the county are hopefully on the downhill side of the peak, we are prepping to get there soon. For the guys that have seen a ton thus far, what do you think of the seeming trend away from early intubation and towards avoiding intubation with HFNC? Also, I have read about some folks going with APRV initially with decent results, anybody here have a similar experience? Overall, what has seemed to work best for those that have been in the hardest hit areas?

I've been against early intubation from the start given the concern that this would lead to a shortage of ventilators quickly if there was a large spike in local COVID cases. Our ER/ICU protocol is HFNC for anyone requiring more than 6L NC and we will get them up to 40LPM/100% FiO2 before considering them a treatment failure.

As for vent settings, I know there has been a push for APRV from some in the EM community but I don't really understand it. The disease process we are treating is still ARDS. We know that the ARDSnet protocol has trial proven mortality benefit. Also, most of our RTs are not familiar with APRV.