Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: On December 31st, 2019, China reported a cluster of cases of pneumonia associated with the Hunan seafood wholesale market in Wuhan.
Speaker: On January 7th, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronavirus.
Speaker: Since then, the number of cases and fatalities has increased with over 115 countries now reporting confirmed cases.
Speaker: In our previous episode of Critical Matters,
Speaker: we discussed initial impressions and early understanding of this novel coronavirus epidemic.
Speaker: Since then, the pace of spread has accelerated as well as the amount of information being shared.
Speaker: Today, we will provide an update on COVID-19.
Speaker: Our guest is once again, Dr. Raquel Nara.
Speaker: Dr. Nara is an infectious disease and critical care physician.
Speaker: Dr. Nara is the assistant professor of medicine in the divisions of infectious disease and critical care medicine at Cooper Medical School of Rowan University.
Speaker: She's a practicing critical care and infectious disease physician, as well as a hospital epidemiologist at Cooper University Hospital in Camden, New Jersey.
Speaker: Raquel, welcome back to Critical Matters.
Speaker: Hello, Sergio.
Speaker: So as we had closed the last episode, I said, I mean, that we would love to have you back.
Speaker: I didn't expect that it would be so quickly, but I think that considering what is going on the ground and the pace of this epidemic and the pace of new information,
Speaker: I thought that it would be of great value to our listeners to do an update on what's going on today with COVID-19, which is the new name of the disease.
Speaker: So why don't we start with maybe a quick snapshot or where we stand today in terms of the last situation report worldwide and as well here in the United States.
Speaker: So, well, just an update of the numbers.
Speaker: As of today, we have a total of 118
Speaker: 118,000 give or take cases worldwide, with the US having 972 cases.
Speaker: Just maybe two days ago, the US had less than 500 cases.
Speaker: So you see how the pace is picking up very fast, not only on numbers, but also, as you mentioned earlier, regarding the amount of information and knowledge we have of this
Speaker: clinical disease.
Speaker: Still a lot to learn, but we have much more now than we had when we talked a few, a couple of weeks ago.
Speaker: And I think that one of the important aspects of where we stand today and today's March 10th in the evening is that at this point, coronavirus is present in the United States.
Speaker: And really, I mean, most of our efforts are going to move forward in terms of mitigation
Speaker: and not a containment because probably clinicians that are listening to this right now are probably treating already coronavirus.
Speaker: And I think that, like you said, it's very rapidly evolving.
Speaker: And I presume, Raquel, that as testing becomes widely available and is disseminated through other channels and local state departments and CDC, that number of 900 plus will probably grow very, very quickly, right?
Speaker: Absolutely and we have to be cognizant that there will be also limitations with the capacity of those testings.
Speaker: So even though it's being advertised that we're going to have unlimited testing capacity, I think we're going to reach a limit where we won't be able to test everyone that comes through the door and we're going to have to rely on some kind of criteria like what happened some
Speaker: clinical or presumed diagnosis of COVID-19 based on clinical features.
Speaker: But absolutely correct.
Speaker: As we have more testing capacity, we're going to see an increase in number of cases.
Speaker: And I think that during this episode, we really want to provide an update on actionable items that are going to be of relevance to our bedside providers.
Speaker: I think that for some of the history of this epidemic and some other general information,
Speaker: I would refer people to the links that will be attached, but also to the previous episode.
Speaker: But before we dive into updates on management, can we just make sure that we share with everybody and clarify this virus now has a new name and the disease has a new name?
Speaker: And just so people understand what we're referring to, could you clarify what SARS-CoV-2 is versus COVID-19?
Speaker: Yes, so it's very important to understand the distinctions.
Speaker: So COVID-19 represents, it stands for coronavirus disease 19, referring to the year 2019 when it was first described.
Speaker: And that refers to the clinical presentation of the disease.
Speaker: SARS-CoV-2
Speaker: is the virus, is the name of the virus that causes COVID-19.
Speaker: And I think they came up with the nomenclature earlier, late in February, if I'm not mistaken.
Speaker: And at that time, the understanding was that
Speaker: it tried to encompass what they're seeing, which is the SARS picture.
Speaker: But because we already have a SARS-CoV, which is the one, the etiologic agent of our prior SARS outbreak, this one got the number two next attached to it.
Speaker: The nomenclature, yes.
Speaker: Go ahead.
Speaker: Go ahead.
Speaker: Deciding to have that name, it's okay.
Speaker: To
Speaker: The choice of this name had some controversy to it in the sense that science or the expectation is that the virus will be attenuated with time, and having a name of SARS-CoV-2 might not be relevant in a couple of years.
Speaker: But I think for now, it has the appropriate name because it does correlate with the severity of the disease that we are seeing in some patients.
Speaker: Excellent.
Speaker: So I think to clarify and reinforce, SARS-CoV-2 is the name of the virus and COVID-19 is the name of the clinical disease that we'll be discussing.
Speaker: So I think for the rest of the podcast, we'll probably be referring to COVID-19 as a term that we'll be utilizing and it's in reference to the clinical disease that we're trying to identify and that we're trying to treat at this point of the epidemic.
Speaker: So with that out of the way, I think that we can start maybe by talking about triage, which I think is the first point where I think people are having difficulties.
Speaker: And when I mean by triage, I mean identifying patients who might be at risk.
Speaker: I think that initially a lot of the efforts were geared around identifying travel or exposure history.
Speaker: My understanding is, Raquel, that at this point, especially for critical care doctors, anybody who has an undefined severe respiratory illness, which means a respiratory illness that is bad enough to require being hospitalized, is probably at high risk at this point in the United States of having COVID.
Speaker: Could you tell us who we should be suspecting COVID-19 in at this point?
Speaker: Absolutely.
Speaker: So you're right.
Speaker: The new criteria released by the CDC on March 8th expanded the number of people that will be tested.
Speaker: And I'm going to just define them briefly so that we have an understanding of them.
Speaker: So they want anyone with fever or signs and symptoms of lower respiratory illness and shortness of breath.
Speaker: And then the third tier to that will be either they are individuals that are older
Speaker: above age 65.
Speaker: and individuals with chronic medical conditions, for instance, or immunocompromised, that will have a higher risk of having a poor outcome.
Speaker: And those higher risk include diabetes, heart disease, being on immunosuppressive therapy, having chronic lung disease, chronic kidney disease, so on and so forth.
Speaker: They also included in patients who
Speaker: are being hospitalized because you need to make decisions regarding your infection control practices.
Speaker: And the third category will be those with signs and symptoms or fever and any healthcare provider who had been in contact with somebody who had a lab-confirmed COVID-19
Speaker: patient or had a history of travel to one of the affected areas.
Speaker: And those areas are, at this point in time, the CDC is saying Japan, South Korea, Italy, Iran, and China.
Speaker: So once you meet those criteria, then you should start thinking of COVID.
Speaker: I want to point out that the fever they're talking about is a fever of 100.0, which is not very elevated, as you can imagine.
Speaker: So with this criteria in place, you can imagine how
Speaker: broad and how many patients now you're going to be faced with the question that you want to test for COVID-19 or for the virus SARS-CoV-2.
Speaker: And that creates a lot of bottleneck because one, you won't get the results quickly.
Speaker: And two, what do you do with the patient that you are ruling out
Speaker: And three, you're going to have a lot of people that you have in some form or sort of precautions, whether it's droplets with contact, droplets with contacts and airborne.
Speaker: And we are facing a reality where we are going to have shortage in PPE.
Speaker: Therefore,
Speaker: I think we need to be cognizant of what are those signs and symptoms of fluorespiratory tract infection that we are expecting to see in patients who have a viral pneumonitis.
Speaker: With viral pneumonitis, the findings are very specific.
Speaker: You are looking for specific findings of acute respiratory distress syndrome.
Speaker: You're looking for interstitial lung infiltrates.
Speaker: brown glass opacities on CAT scan.
Speaker: Often those patients will have leukopenia, lymphopenia more prominent, but their Y count will not be very elevated.
Speaker: And you will see a procalcitonin that suggests a viral illness.
Speaker: So with that in mind, I think it's important to be cognizant of
Speaker: what are the features that you are looking for?
Speaker: Because you cannot possibly test every low-grade fever with some respiratory illness.
Speaker: I can tell you what we are doing.
Speaker: What we are doing in our institution is we are making sure you're ruling out influenza A and B because we have to remember that we're still in peak season with very high volumes of influenza A and B throughout our state.
Speaker: And if that's negative, we check for viral panels that include parainfluenza, adenovirus, rhinovirus, RSV, human metanemovirus.
Speaker: And though our panel doesn't have that, I think it's important if we have the ability to check for mycoplasma, PCR, and the ability to check for
Speaker: other virus, like the other coronaviruses, human coronaviruses that have been described in the literature to cause pneumonitis.
Speaker: And if those are negative, then we are taking it to a second tier, where at that point, if we're still suspecting it's a viral pneumonitis, then we call the state to get approval for the COVID-19 testing.
Speaker: And I think that what's important also from the testing perspective is that that's a very dynamic situation.
Speaker: And I wouldn't be surprised if by the time people listen to this podcast, things may have changed locally.
Speaker: So I think it's very important for clinicians to be in touch with their infection control and with their local state authorities to understand what their institution is offering and what are the options for testing.
Speaker: Now, before we move on, what I wanted to kind of reemphasize or circle back to
Speaker: is two things, Raquel.
Speaker: Number one, from a perspective of a critical care clinician or a bedside provider in critical care, clearly we see a pattern of fever, filial infiltrates, lymphopenia, we should be thinking COVID-19, right?
Speaker: So that's, I mean, seems to be a constellation that would be highly suggestive in the current situation of a potential patient.
Speaker: And would it be fair to say that in any case,
Speaker: that we are intubating patients with respiratory failure of unknown origin or that we're unclear what the real cause is, that we should be extra cautious and be using proper PPE?
Speaker: Absolutely.
Speaker: And by proper PPE, I think we need to emphasize what we mean by that.
Speaker: You should be wearing an N95 mask, you should have a face shield, and you should have gown, gloves.
Speaker: and you should dump them properly, and you should doff them properly, meaning you remove your gown first, you do hand hygiene, and then you remove your face shield, removing the, remove the face shield, hand hygiene, then remove your N95 and do hand hygiene.
Speaker: You wanna do absolutely the right order and perform hand hygiene between steps so you are not contaminating yourself.
Speaker: And I think that that's a super important topic in terms of like the power of proper hand hygiene, which is defined as a good water and soap for 20 seconds or more, including your thumb, which I think often people neglect, or using an alcohol-based product with 60% of alcohol or higher for 30 seconds at least and leaving it to dry by itself.
Speaker: So I think not only is that important, but like you said, I think
Speaker: And this is something that I know for a fact because I've served providers.
Speaker: We usually don't remove our PPE in the right order, and we don't use hand hygiene in between every step.
Speaker: So this is not the time to be in a hurry.
Speaker: And I think that as leaders at the bedside, we should be encouraging our teams to do the proper steps and to do it slowly and to make sure that they're doing the proper hand hygiene in between each step.
Speaker: Now, I think this is a great opportunity to talk about infection prevention and control and what is new or what has changed.
Speaker: So I think that one of the items that I think needs to be emphasized over and over again is that as in any infection, step one is source control.
Speaker: And what does that mean in COVID-19?
Speaker: It means putting a mask on any suspected patient, right?
Speaker: Absolutely.
Speaker: And I'm going to take you a step further.
Speaker: So
Speaker: I think having your, putting the mask on the patient is number one.
Speaker: Intubating a patient if needed, and we can talk about this a little bit later, is another form of source control.
Speaker: And I think we need to mention that when we start talking about modes of ventilation, whether we're doing invasive or non-invasive ventilation of those patients.
Speaker: So masking your patient, rooming your patient, or if you don't have a way of rooming your patient and you don't have a good triage, not a good triage, like a triage was a good aeration system, having maybe the patient wait in the car and then you call that patient in when you're ready for him to be examined, as opposed to leaving the patient in your waiting room.
Speaker: If you are able to separate your influenza-like illnesses from your general population, then you don't need to go to those extreme measures.
Speaker: But if you don't have such a capacity, that wouldn't be a bad idea to take the patient to make a wait in the car if you don't have an available room for the patient to be roomed immediately, even before registration.
Speaker: into a room and then you can take the registration either by phone and then have him sign the HIPAA forms.
Speaker: Later when the physician or the nurse go there to either talk to the patient or get vital signs, they can make the patient sign those forms.
Speaker: Those are important steps to think about because you want to protect your force.
Speaker: You want to protect your healthcare providers and you want to protect your ancillary service and you don't want to expose them.
Speaker: And does that apply?
Speaker: I think that we'll get there in a second, but
Speaker: I guess one of the things that I'm hearing is people start thinking as the numbers increase of what are also mechanisms of cohorting these patients either in ED areas or in ICU areas so that we put them, if you have two units, maybe one of them is dedicated to the COVID patients.
Speaker: Because right now the recommendation, Raquel, is to use droplet precautions, contact precautions, and place these patients in airborne isolation rooms.
Speaker: But
Speaker: I suspect that as the numbers keep increasing, we are gonna outsource or we're gonna run out of airborne isolation rooms.
Speaker: Could you tell us what the current recommendations are for isolating these patients?
Speaker: So, and I'm glad you mentioned, before we started this podcast, I was browsing over the CDC guidelines.
Speaker: They just released a interim practice update.
Speaker: And in that update,
Speaker: they scaled back in their recommendations of airborne.
Speaker: So you want to put the airborne room, patients on whom you're expected to have frequent diuralization.
Speaker: You have the patient on albuterol nebulizers every four hours, or you decided not to intubate the patient and you have them on BiPAP instead, and you're trying to BiPAP them before bridging them or, you know, hoping they'll get better and you don't need to intubate them.
Speaker: We talk about that because I don't think it's the right way of doing it, but this is the practice that we've been doing for a long time, where we try to avoid the mechanical ventilation in most of our patients, if possible.
Speaker: So for those patients, you want them in the negative pressure rooms.
Speaker: Every other patient, like the intubated or the one
Speaker: that can't tolerate to have a face mask in their face, those patients, you can have them in droplet and contact precaution.
Speaker: And even though we do believe that the mode of transmission is droplet, certain the capacity of IRLized procedures to generate small particles that can infect the healthcare providers is not fully understood.
Speaker: And therefore, at this point in time, when you are performing such procedures, I think it's important to have the N95.
Speaker: I would like to mention what those procedures are since we are on the topic.
Speaker: And those, I think we touched on them a little bit last time we talked, but I think it's good to remind everyone about them.
Speaker: If you are performing resuscitation, CPR,
Speaker: It's important that you have your N95.
Speaker: Make sure you limit the number of people around this bed that you are resuscitating.
Speaker: You should also... Tracheal intubation, as we mentioned.
Speaker: This constitutes a manual ventilation before intubation, the bag mask, the bag, the bag, or bag mask ventilation.
Speaker: that can generate a lot of aerosol and contribute to transmission.
Speaker: As we mentioned before, non-invasive ventilation and vacheostomy.
Speaker: So those would be the procedures that have been associated with healthcare providers being infected with the SARS-CoV-2
Speaker: the first one, and we think it's the same process for SARS-CoV-2.
Speaker: So I would highly emphasize to make sure you protect yourself.
Speaker: Having the right PPE will preserve your healthcare providers, meaning you will have less exposure, and if you have less exposure, you are less likely to quarantine and expose
Speaker: and exposed healthcare provider.
Speaker: So I think it's important.
Speaker: And I think that's super important.
Speaker: And I think it's also important to emphasize, Raquel, that right now, the most important precaution is preventing droplets, which we do through droplet and contact precaution and proper donning and removal of PPE with hand washing.
Speaker: Now, initially in the epidemic, airborne isolation
Speaker: for negative facial rumours was recommended, but like you said, right now we are going to be in a situation where that's not going to be enough.
Speaker: So also considering what are the known patterns of contagion and what are the high risk procedures, intensivists and ED physicians should prioritize airborne isolation or negative flow isolation for patients in whom they're intubating.
Speaker: patients who are on high aerosolized situations, like you said, we'll talk about that a little bit later, BiPAP and high flow oxygen, but it is okay by CDC recommendations at this point to have patients who are intubated, who are not receiving these procedures in a non-negative pressure room.
Speaker: Is that correct?
Speaker: That's absolutely correct.
Speaker: And if you look at the WHO guidelines, they're more lax than the CDC guidelines where they only emphasize
Speaker: that the provider put an N95 mask, even if the patient stays in a droplet contact precaution type of situation.
Speaker: If you are doing a nebulized treatment to the patient, then you make sure that the provider performing the procedure, the nebulization puts on the N95 with the face shield.
Speaker: So even though our
Speaker: Certain places in the US adopted the WHO recommendations because they are, in a way, they're less strict.
Speaker: They allow you to preserve some of your PPE.
Speaker: They seem to be protecting healthcare providers.
Speaker: And at the same time, they take into consideration the limited numbers of airborne rooms we have.
Speaker: Like most units don't have more than two.
Speaker: negative room pressure, negative pressure rooms.
Speaker: So I give you, for example, our unit, we have two rooms that are negative pressured in our medical ICU.
Speaker: So if we have four patients, that becomes a problem.
Speaker: You're not going to have them share rooms, right?
Speaker: So we don't have this capacity.
Speaker: It's all these single room areas.
Speaker: And so we have to be practical and adapt ourselves with what we have.
Speaker: keeping in mind the health of your provider as well as of your patient.
Speaker: But we need to preserve our workforce.
Speaker: That's important.
Speaker: That's, I think, an important point.
Speaker: And I think that what we just discussed, Raquel, also illustrates to our audience the rapidly evolving nature of the situation and how information is literally being updated by the hour with guidance
Speaker: and as the situation on the ground evolves, but also as we get better information.
Speaker: But I think that as clinicians and leaders at the bedside, we should try to have the best information available and focus on the things that we know or believe are probably much more relevant.
Speaker: And I can't overemphasize that for protecting the healthcare providers, it is the proper hand washing and proper PPE use that is most important.
Speaker: And the N95 masks are very important in these high risk situations like intubation and valuing patients on BiPAP, which we'll talk about, bronchoscopy, which I don't think really is indicated for these patients at this point and other situations that you mentioned.
Speaker: So let's move on, Raquel, to diagnosis.
Speaker: We talked about what are some of the reasons to suspect COVID-19.
Speaker: And we talked a little bit about
Speaker: how you might proceed.
Speaker: But you did mention that in terms of clinical presentation, we talked about respiratory illness with undefined cause.
Speaker: We talked about possible bilateral infiltrates.
Speaker: We talked about lymphopenia being something that seems to be common and characteristic.
Speaker: Even if patients have a mild leukocytosis, they might still have lymphopenia.
Speaker: You did mention procalcitonin, and I just want to make sure that the audience is very clear on this.
Speaker: you were referring to a normal procalcitonin, which is what we see usually with these viral diseases.
Speaker: Is there anything else that you want to mention in terms of diagnosis?
Speaker: So I think it's important to mention that the imaging.
Speaker: Imaging has been shown that a CAT scan is a normal CAT scan rules, almost rules out COVID-19.
Speaker: a normal chest x-ray, a chest x-ray can be normal in up to 50% of the cases, so you cannot absolutely rely on a chest x-ray.
Speaker: In 83 or 90% of the cases, you're going to see some kind of abnormalities on a CT scan done on those patients.
Speaker: Some of the issues that in ordering too many scans is that you have to think about how you're going to
Speaker: in the room the cat scanner after the patient is out of after you take the patient you know you do the scan and then you wheel the patient out what is your procedure of cleaning those cat scanner and the reason i'm saying that is that if you have a covet 19 case that's easy like you know easy or
Speaker: You have to make sure you have a certain number of exchange in the CAT scanner and that you terminally clean the CAT scanner so you're not supposed to go immediately back into the room.
Speaker: So that might cause a bottleneck or a delay in other imagings that you might want to do for other patients.
Speaker: That's something to think about.
Speaker: But as for COVID per se, having a negative CAT scan almost rules it out.
Speaker: And a positive CAT scan has a lot of value pushing you for, you know, guiding your next step testing.
Speaker: Because even though we do understand that we will have commercial
Speaker: lab for COVID-19, which is in RT-PCR testing, the sheer number of cases is going to overwhelm the commercial labs at some point.
Speaker: And we're going to have to resort back to those clinical findings.
Speaker: So the CAT scan, we talked about procalcitonin.
Speaker: D-dimer has been linked to poor outcome.
Speaker: I don't know if I would rely solely on D-dimer as a marker.
Speaker: We mentioned
Speaker: Leukopenia.
Speaker: Most of those patients that have some increase in their liver function, EST and ALT.
Speaker: And the other one would be the procalcitonin, as we said.
Speaker: CRP tends to be elevated in those patients.
Speaker: I would not recommend checking all of those.
Speaker: We check, for instance, procalcitonin.
Speaker: You can also check for, make sure you've ruled out other etiologies.
Speaker: So it's important if you're just relying on your chest X-ray to check your ProBNP.
Speaker: Because sometimes if you have, you know, you can have an MI and have a low-grade fever.
Speaker: So a temperature of 100.0 in a patient who just had an acute MI would not be unheard of.
Speaker: So that's something to keep in mind, you know, check your ProBMP, make sure there's no heart failure to explain those interstitial infiltrates on the chest X-ray.
Speaker: And I think that that's an important point in terms that a lot of these cases,
Speaker: when we first evaluate them are going to be undefined in terms of the etiology, we might be suspecting COVID-19, but we also have to check for everything else, like you mentioned, not only getting appropriate viral panels, but also getting regular blood cultures before we give antibiotics.
Speaker: This could be bacterial, making sure we're ruling out cardiac causes and just with the history, trying to figure out could there be some other cause.
Speaker: So doing the usual things that we do to diagnose these patients with respiratory fare is going to be also
Speaker: very important and make sure that we are identifying cases that are not related to COVID-19 because we will still see patients who will come with other causes of respiratory failure.
Speaker: And I think it's important to recognize those.
Speaker: Why don't we move to talk about early supportive therapy and just in terms of some recommendations and we can then talk of the management of
Speaker: hypoxemic respiratory failure with ARDS in these patients, which I think is what most of our ICU friends and audience is going to have to deal with.
Speaker: So in terms of early supportive therapy, obviously, oxygen is going to be a mainstay of therapy.
Speaker: Start supplemental oxygen, trying to keep the SATs over 90% for most adults and over 92% to 95% for pregnant patients.
Speaker: Although I do understand, Raquel, that we don't really have a lot of guidance or specific literature on pregnancy, right?
Speaker: No, we don't.
Speaker: All the literature that I could pull or recommendations that I could pull from the CDC are some guidance on postpartum lactation and mostly referring to lactation.
Speaker: I think that an important point in this patient, and I want to see your opinion, is that since we're still evaluating them in the early phases, early use of empiric antibiotics as per sepsis protocols would be appropriate.
Speaker: And as we wait for cultures and try to figure out what's going on,
Speaker: I think that's important, not because we think there's a high risk of super infection, but because we don't know these patients might be coming with bacterial pneumonia, right?
Speaker: Correct.
Speaker: And my understanding, Raquel, with the super infections is that with the exception of the Chinese series, which had an increased risk of gram-negative rods and fungal infections, we're not seeing a very characteristic or high incidence of super infections.
Speaker: And some people believe that
Speaker: in the Chinese series that might have been driven by the high use of corticosteroids.
Speaker: Is that what your read is and what your understanding is currently?
Speaker: So unfortunately, and that's one of the things that I'm trying to wrap my head around, is that we don't have a lot of peer-reviewed data coming out of the US so far, even though we have 972 cases and we do have some experience with, you know, we know we do have big focuses in the West Coast.
Speaker: Nothing came out officially from the CDC telling us what's happening, how they're treating those patients.
Speaker: From the grapevines and different conferences that has happened in the West Coast, as you said, we don't see a lot of nosocomial bacterial pneumonia, at least not to the same extent that we were seeing with influenza.
Speaker: And I absolutely believe that the gram negatives and the fungal infections that you were seeing with the Chinese cohort
Speaker: is more related to the early use of corticosteroids.
Speaker: You have to understand that the corticosteroids tend to make the patient's respiratory oxygenation improve, but that's at the cost, and the cost is you're shedding more of the virus.
Speaker: And this is why the CDC came out with an absolute recommendation of not using steroids
Speaker: unless you absolutely need it for some other condition on the patient.
Speaker: Let's say the patient is now in septic shock, or the patient is showing shock symptoms, and you want to start steroids for adrenal support, or the patient has chronic adrenal insufficiency, and you need the stress dose of steroids.
Speaker: So in certain situations, you might want to use your steroids, but not to use steroids on every single patient you have.
Speaker: Yeah, and I think that this is something that I'm seeing more and more being overemphasized is that the use of corticosteroids is not recommended and that could be detrimental to our patients.
Speaker: So I think that, like you said, if you have a very specific indication, you might consider it.
Speaker: But I do think that we have to be careful with a report suggesting that because it's a very high inflammatory disease, that an anti-inflammatory such as steroids would be helpful.
Speaker: Absolutely.
Speaker: Let's talk a little bit about the management of the respiratory failure per se.
Speaker: And I think that you talked a little bit earlier, Raquel, about the potential perils of using either non-invasive ventilation via BiPAP or via high-flow oxygen such as Vapotherm in terms of the potential to disseminate droplets and create a high aerosol situation that could facilitate contagion.
Speaker: I think that that is one reason why some people are a little bit hesitant, but I also think that it's important to point out to our colleagues that in most of the series that have been published, the critically ill patients, there's a high failure rate with noninvasive ventilation.
Speaker: And in some series, it's been associated with increased mortality.
Speaker: And the thought there is that maybe you're delaying proper therapy with intubation.
Speaker: So I think that on the sum of all these findings,
Speaker: It would seem that unless you have a very mild case, that most patients, we should really not waste a lot of time trying BiPAP and trying vapothermins and escalating oxygen through that delivery and really move to early intubation and move forward with securing that airway and also producing source control by creating a closed circuit, like you mentioned.
Speaker: What are your thoughts on that?
Speaker: What you said is absolutely correct.
Speaker: So you have to think about how the disease progressed.
Speaker: So think that one, we don't have, we're only providing supportive care.
Speaker: We don't have so far, so there is some studies ongoing now for remdesivir and its usage in patients to prevent, to halt the progression.
Speaker: And some of the findings, the early results seems to be very encouraging.
Speaker: However,
Speaker: we don't have a MNC.
Speaker: So this is only obtained right now via compassionate use or via trial, through a trial.
Speaker: So with that in mind, now you have a disease which progression seems to be once you get to the long stage and you are progressing into ARDS,
Speaker: but you cannot treat the etiology of this ARDS.
Speaker: So with that concept in mind, it doesn't make sense to me that you would support the patient with non-invasive ventilation.
Speaker: You know, if you don't have a way of halting the progression of the disease or the virus, you're going to have to provide maximum support to get the body to heal itself.
Speaker: with that in mind, that's why to me mechanical ventilation would be an early mechanical ventilation with intubation will not only have good practices in the sense preventing the shedding of the virus, but it also will allow you to provide optimal support to the patient and you know and
Speaker: doing what we know works, low volume ventilation as proposed by ARDSnet.
Speaker: So I think moving through those is very important and understanding that that concept makes you accept the fact that we're not going to do the usual way, which is try to avoid ventilation, sorry, avoid the intubation of the patient.
Speaker: We're going to move the other, yeah, intubate.
Speaker: I think that's an important point.
Speaker: And I think that the other point that I'm going to make, and this is food for thought for our audience, because I think there is no guidance on this and there is no literature on this.
Speaker: But historically, I think a lot of providers and clinicians have utilized BiPAP and non-invasive ventilation as a mode of ventilation, especially in patients who are resuscitated, do not intubate.
Speaker: or who we might be putting certain limits on care.
Speaker: This is something that we're going to have to evaluate, I think, very carefully if it comes to a situation where we have patients who are COVID-19, who are not to be intubated, who don't want to be resuscitated in terms of how we manage them, because we would just probably be putting them on a therapy that's not going to make a difference or help them, but that could expose healthcare workers to an increased risk
Speaker: without any benefit for the patient.
Speaker: So I'm not gonna ask you to make a comment on that, Raquel, because I think that there's no evidence for that.
Speaker: I'm just planting it as something that our teams should be thinking about as things progress and we see more of these patients.
Speaker: But let's talk about intubation.
Speaker: And I think that you already have identified that early intubation is probably the way to go in terms of treating these patients for supportive care for all the reasons you mentioned.
Speaker: it's also a very high risk situation and perhaps the highest risk situation that intensivists will face.
Speaker: And I think that there are some things that we should do and some things that we should avoid based on my reading.
Speaker: So what I would like to do, Raquel, if it's okay with you, is to give a list of do's and don'ts and then have you comment on what I left out or what are your thoughts on that respect.
Speaker: So it seems that if we're gonna intubate somebody, airborne precautions,
Speaker: if available, should be utilized for this situation.
Speaker: Clearly for the people involved with the intubation, using an N95 mask that has been fitted and full PPE, which includes gowns, standard gloves, and a face shield, super important.
Speaker: Like I said, negative pressure isolation room.
Speaker: And I think that two things that I have recommended my clinicians, and I think that we're seeing more people talk about this, is number one, this is a great situation.
Speaker: where we should be utilizing technology such as video laryngoscopy, glidescopes, CMAX, because I think that it allows us to be removed from the airway as much as possible as the operators, and it's probably also assures a quicker intubation.
Speaker: The second thing I would say is that we should use rapid sequence intubation in these patients and minimize to avoid bagging once the patient is ready to be intubated.
Speaker: And finally,
Speaker: I think that this is a situation where the most seasoned person should be intubating.
Speaker: So especially for those of you who are in teaching hospitals, this is not the type of patient that you're going to teach your residents to intubate on because I really think that minimizing the time that the patient is being intubated and getting this right the first time is super important.
Speaker: In terms of don'ts, I think that you already mentioned it several times, Raquel, try to avoid the use of BiPAP
Speaker: high flow oxygen, vapotherm, etc.
Speaker: Don't allow non-critical staff in the room.
Speaker: So people who are in the intubation process should be there if they have a role.
Speaker: We don't need extra people in a room where there's a high likelihood of aerosolite droplets.
Speaker: If possible, minimum bagging after you're ready to intubate.
Speaker: So pre-oxygenate and then minimize the bagging trying to keep a closed circuit at all times.
Speaker: And finally,
Speaker: Don't use PPE outside of the room if possible.
Speaker: Take the PPE out in the anteroom as you're leaving in the proper fashion.
Speaker: What are your thoughts, Raquel?
Speaker: Is there anything that are missing or any other thoughts on intubation that you think are important to emphasize?
Speaker: It's important to make sure that not only the N95, but I want to emphasize the face shield and eye protection, even if you wear, or goggles, even if you wear glasses.
Speaker: I would also make sure that we have a gown and of course the gloves, it goes without saying.
Speaker: But because the gown and sometimes I worry people feel that the
Speaker: the glasses or protection, they're not.
Speaker: You have to have a face shield for eye protection.
Speaker: So those are the things that I will add for PPE.
Speaker: I think you touched on all the do's and don'ts of intubation.
Speaker: So with respect to mechanical ventilation, Raquel, I think that as of now the recommendation would be that we have a low threshold to intubation obviously, but once we put them on mechanical ventilation is to follow
Speaker: standard ARDS net protocol with a lower tidal volumes of six mls of predicted body weight that we try to keep the plateau pressures below 30 to 35 and that we really apply, I mean, lung protective ventilation.
Speaker: It seems that I would treat these patients at this point as any ARDS.
Speaker: I think an important point, and then I want to hear your opinion from my perspective, is that you should do the things that you usually do.
Speaker: If you're not doing ECMO,
Speaker: and you're over flooded with patients with COVID-19, that's not the time to start doing ECMO.
Speaker: If you do ECMO, you should select patients for ECMO the same way you do it for other ARDS patients.
Speaker: And I think that we'll probably see more guidance about that.
Speaker: But as far as we know, in the largest series published so far, the percent of patients that went on ECMO is very small.
Speaker: It's 3%.
Speaker: So there's not a lot of information available.
Speaker: And I do think that as a reminder for our audience,
Speaker: A prone positioning has been shown to improve mortality and severe ARDS.
Speaker: So I think that that's something that we should consider early on and probably before you do neuromuscular blockers or you consider ECMO.
Speaker: It makes sure that you are trying that first.
Speaker: What about the concerns, Raquel?
Speaker: I know that you're also very involved with disaster planning at your institution.
Speaker: I know a lot of intensivists ask me about concerns of running out of ventilators.
Speaker: I know that the United States government has stockpiles of ventilators, but what are the thoughts right now?
Speaker: I mean, is there anything that you can share with us from that perspective?
Speaker: So, I mean, you have to have your... So one of the things that the emergency management team is looking into is to not only see who is your suppliers for your ventilators and then trying to figure out how many events you can...
Speaker: rent and making sure that the numbers that they give you is like they can absolutely provide you with those number of them so that's very important to know for your um by your you know from your um imt team there have been talks about using those pneumatic system vents those are designed for acute resuscitation
Speaker: I don't think they will be efficient in our cases because we're talking about ventilating people who are in ARDS.
Speaker: So short of having, we might need to recycle older vans, that's something that's been discussed.
Speaker: Short of having a supplier or knowing who are your sources, whether it's federal sources or getting in touch with the government or your state to have in plan
Speaker: to have a plan in the event you are short of ventilator.
Speaker: And that's something your administration or your IMT team needs to be thinking about as opposed to the clinician.
Speaker: We should be worrying about our patients and raise the question to your leaders so they start thinking.
Speaker: Because remember, some of your leaders are not physicians and they might not think about those
Speaker: some details.
Speaker: Like for instance, they offered us to have those traumatic vents, which is they cannot support the high peeps and they won't beep if there is a loss in pressure, so on and so forth.
Speaker: So when they presented it to me, I was like, no, this won't work because I cannot vent an ARDS patient.
Speaker: So that's something that you need to be aware of.
Speaker: And I think that another very important aspect of ventilators
Speaker: is that if you look at the numbers probably depending where you read and who you talk with but i would say that as an approximation there's probably around 60 000 full capacity ventilators in the united states currently in operation in hospitals and maybe there's another 90 000 that are stockpiled of those half probably have full capacity like you mentioned they're not all full capacity ventilators but i do think that a lot of intensivists have asked me about ventilators but
Speaker: when you really talk about people who are experts in disaster management, the limiting factor might not be the ventilators, but could also be respiratory therapists.
Speaker: I mean, you need people to manage these ventilators and hospitals might already be at capacity for that.
Speaker: And especially if healthcare providers get sick as the epidemic advances, that might be also a very important point.
Speaker: And I think that's something to think about and things that we can ask at our local institutions.
Speaker: Is there a, we talked a little bit about, but I think it's worth revisiting once again, is specific treatments for COVID-19.
Speaker: You mentioned that we have none, but can you just remind people what are the things that people have published and talked about and what is the current CDC recommendation or what's available in United States for this?
Speaker: Okay, so the current CDC, if you open the CDC site, they tell you supportive treatment.
Speaker: Having said that,
Speaker: there have been some antiviral that had shown some promising features.
Speaker: I'm going to start with the lopinavir-ritonavir, which is Calitra.
Speaker: This is a protease inhibitor combination that we have shown during the SARS outbreak that it has good, it works.
Speaker: And it was actually two trials.
Speaker: Retrospective, the first one used lopinavir 400, ritonavir 100 orally twice a day.
Speaker: They showed that the death rate with the treatment group was 2.3% versus 15.6% for the control group.
Speaker: And then the rest rate of the lopinavir-ritonavir rescue group was 12.9%.
Speaker: compared to the control, which was around 14%.
Speaker: So the addition of the lopinavir, ritonavir to a standard treatment seems to be logical.
Speaker: This was published, I think, in the, it was in Hong Kong, a medical journal.
Speaker: And even though they had a large cohort, and they were doing prospective,
Speaker: they did not randomize the patients.
Speaker: So that created some kind of, you know, it's a weakness of the study that we cannot, you know, go back and change.
Speaker: But it did show good promising results.
Speaker: The second study was published in Torax in 2004.
Speaker: And in that study, they showed that the hypoxemia was improved in the lopinavir, ritonavir group.
Speaker: And the
Speaker: the lupinavir-ritonavir group was associated with a better outcome.
Speaker: But this was a study that looked at the historical controls, so there was no randomization, and that's the caveat in there.
Speaker: So it could be that the positive effects of the lupinavir-ritonavir were exaggerated by the very poor outcome
Speaker: that the control had.
Speaker: It was not the same time, not the same era, not the same way of managing things, so you cannot tell whether if it was the effect of glupinavir versus change in practice.
Speaker: So those are two studies.
Speaker: There is currently a study, I think, going on in Taiwan and one in
Speaker: I think, South Korea regarding lopinavir and ritonavir, so more to come in those studies.
Speaker: Remdesivir, as I mentioned earlier, is an agent that's developed by Gilead, and it's an experimental agent which was developed for Ebola and Markovirus, and that seems to have promising effects in
Speaker: COVID-19 cases.
Speaker: There is two trials ongoing in the US right now, one which is initiated by the NIH and it uses remdesivir versus placebo.
Speaker: And the other one has been initiated by Gilead and it's remdesivir five days versus remdesivir 10 days to see the duration of treatment, which one you should go with.
Speaker: So those are the ones that have been studied right now.
Speaker: And I think that, Raquel, from what you're telling me, my interpretation is that a lot of our efforts always are centered in what's in front of us, but we should be thinking that these type of pandemics will happen again.
Speaker: COVID-19 might be something that we see again.
Speaker: So I think that with no clear benefit of a specific antiviral, perhaps our best step forward
Speaker: is to try to include our patients in these studies so that we actually get answers
Speaker: of what might be helpful for the future.
Speaker: What are your thoughts on that?
Speaker: That's absolutely correct.
Speaker: So, and I mean, as I said before, like there's very little you can do.
Speaker: And then you want to get those patients better, obviously.
Speaker: And something that works against the virus seems to be the logical way to go.
Speaker: And we know that from, this is a dogma that we use when we treat patients.
Speaker: So you want to treat the bacteria that's causing the pneumonia.
Speaker: You want to treat the influenza that's giving you
Speaker: the pneumonitis on your patient.
Speaker: And logically, you would want to treat SARS-CoV-2 that's causing COVID-19.
Speaker: Having a drug that does that is absolutely crucial in managing those patients.
Speaker: Having said that, remdesivir is currently being used through those trials, but many institutions are getting the drug through compassionate use
Speaker: And I think at some point the company is going to have to stop the compassion that you.
Speaker: So it's very important that you initiate the steps that will take to get the trial in your institution because that could save your life.
Speaker: Absolutely.
Speaker: So I think that's an important thing to emphasize.
Speaker: As we close, Raquel, I think that there are some interesting clinical pearls that have emerged and I'll just...
Speaker: share some, and then maybe you could add some color or add some of your own.
Speaker: But it seems that most of these patients who have severe respiratory illness associated with COVID-19 are getting sick on the second week of their symptom development.
Speaker: So usually they develop symptoms and it usually is the medium time to onset of, from onset of symptoms to ARD is around eight days.
Speaker: And then those patients who die in the ICU, the medium time from ICU admission to death is seven days.
Speaker: So they die, I mean, quickly.
Speaker: And it seems that mortality has been associated with older patients over 65.
Speaker: And every decade that you go beyond that, the mortality is a little bit higher.
Speaker: Like you said, comorbid conditions, including diabetes, immunosuppression, heart disease, hypertension, and cancer.
Speaker: Also important, one series showed that the D-dimer above one
Speaker: Microgram per liter was associated with a higher mortality as well as higher SOFA scores.
Speaker: And it seems that these patients, ultimately, their main organ dysfunction is pulmonary, so it's ARDS, and they die from ARDS.
Speaker: Some patients have multi-organ failure.
Speaker: They can have AKI, abnormal liver functions in a third of the cases, like you mentioned, arrhythmias and heart injury as per troponin.
Speaker: But it really seems that a distinction between COVID-19 and influenza is that an influenza
Speaker: patients can get sick very suddenly and deteriorate very quickly, whereas in COVID, it's usually several days of symptoms before they really start getting very sick in terms of coming to the ICU.
Speaker: Any other comments or additional pearls that you might want to add, Raquel?
Speaker: I think you touched on most of them, and some of the features that I would like to re-emphasize is to start people start thinking about just
Speaker: COVID-19 and combining the clinical picture with your CAT scan.
Speaker: I also want to emphasize that if you find a diagnosis like you have influenza, I don't think you need to start looking for COVID-19.
Speaker: I think that might limit the searching you would do.
Speaker: From the Chinese series, we know that co-infection with other respiratory viruses like influenza or RSV is less than 2%.
Speaker: So if you have a positive for one virus, then you do not need to test for COVID-19.
Speaker: You don't see as many concurrent and bacterial infection as you see with influenza.
Speaker: You mentioned the cardiopulmonary disease.
Speaker: And I think something that maybe we didn't talk enough a lot about is like preparedness of your staff.
Speaker: making sure that you think about staffing.
Speaker: We didn't talk about quarantine of a healthcare provider who has been exposed, but that's something to think about, that if you do have exposed personnel with the wrong PPE, that you might need to quarantine for 14 days, so you'll be losing your workforce for that PPE.
Speaker: And that is also, I think, a moving target, right?
Speaker: Because I saw that the CDC already updated that and said that in some situations, even high-risk exposures in healthcare providers who have no symptoms, it might be okay for them to come back if they consult with their local occupational health.
Speaker: Is that correct?
Speaker: So it depends on...
Speaker: So the risk stratified the level of exposure to high risk, moderate risk, and low risk.
Speaker: And depending on the level of exposure, you might be asked to be quarantined or not.
Speaker: So if you don't have, so I think the latest guideline says if you don't have a face mask and your patient doesn't have a face mask and you were exposed to that patient because you didn't know he has COVID-19, then your risk
Speaker: you become a high risk.
Speaker: And high risk folks will need to be quarantined for 14 days, monitor the temperature twice a day and report symptoms.
Speaker: If they develop symptoms, they will be asked to be placed, you know, they will be checked for COVID-19s and then you start the whole cascade of, you know, checking and making sure that he's getting better.
Speaker: And then, you know, then it's a different
Speaker: a different entity by itself.
Speaker: So it's important to keep that in mind, that even though it's not as strict as it was, where you're going to quarantine everyone who got exposed to that patient, a certain number of providers, and usually it will be your physician, your nurse, or your respiratory therapist, and you cannot afford to use any of those people.
Speaker: So it's important to keep that in mind.
Speaker: So I think that the best way is really to be very cautious in terms of proper PPE.
Speaker: and source control.
Speaker: At this point, that's what we should be considering.
Speaker: Like I said, for us, what we did is that we have every provider seeing influenza-like illness put on a surgical mask with a face shield.
Speaker: I've heard of some institutions that are having any admission for the first 48 hours
Speaker: the patient will go, the physician when they go and see the patient or the nurse will have to put the face mask and the surgical mask.
Speaker: So there is every place is improvising because we're not getting clear guidance.
Speaker: What we decided to do is what will make sure that we can keep our workforce in the hospital, not at home.
Speaker: And that's why we did the face mask was the face shield, seeing any influenza like illness.
Speaker: So you need for that the proper triage.
Speaker: So you need to be able to have those patients go to a separate area and so on and so forth.
Speaker: So Raquel, I really appreciate your time.
Speaker: I think that obviously there's a lot of moving parts.
Speaker: I think that people should stay informed.
Speaker: In our previous episode, we mentioned some good sources of information.
Speaker: I will link those to this episode once again so people can be
Speaker: updated on that.
Speaker: I know that you've been very busy the last couple of weeks and I really appreciate your willingness to get back on the podcast and share with us some of your thoughts.
Speaker: And without further ado, I just want to thank you and we'll stay in touch and stay safe.
Speaker: Thank you, you too, Sergio.
Speaker: Thank you.
Speaker: This is Sergio again and just wanted to close this episode.
Speaker: I think that, as I mentioned,
Speaker: With Dr. Nara, there's a lot of moving parts, a lot of information coming in at a very fast pace.
Speaker: So hopefully this was helpful and will be useful for our listeners and the patients that we're taking care of.
Speaker: As many of our listeners know, we traditionally end the podcast by asking the guest a couple of questions unrelated to the topic.
Speaker: We had done that last week with Dr. Nara, and I want to respect your time, but I do think that it would be worth
Speaker: sharing with you my answers to those questions within the context of what's going on with COVID-19.
Speaker: So I think that in terms of a book that I would read now and gift now to a lot of our friends who are in the midst of dealing with this epidemic, it would be a book called The Obstacle is the Way, The Timeless Art of Turning Trials into Triumph.
Speaker: And this is a book by Ryan Holiday.
Speaker: It really speaks about the application of stoic philosophy
Speaker: to problems in life.
Speaker: I think a lot of the teachings from the Stoics would be very relevant and very useful for what is going on right now, especially the principle of trying to focus on things that we do control as opposed to those that we don't control.
Speaker: And I do think that despite all the uncertainty, there are definitely things that we do control and that we can utilize and make a difference for our teams and for our patients.
Speaker: For the second question I usually ask, which is what do you believe to be true that most people don't believe?
Speaker: I think that I would emphasize, I do believe that hand washing is the single most important thing that we should be doing right now and that we should be taking it very, very seriously in terms of not only what we do at work, but promoting it within our teams, but also in terms of the quality of our hand washing.
Speaker: And I want to make a,
Speaker: comment on that, that we should be using soap and water for 20 seconds or more, making sure that we wash our whole hand, including our thumbs, which are often neglected.
Speaker: I think that if we use alcohol-based products, re-emphasize alcohol-based products with 60% or more of alcohol for 30 seconds or more and for the alcohol product to dry by itself.
Speaker: And finally, I think a point that we mentioned in the podcast
Speaker: that is extremely important is that when we are removing our PPE, we do it in the right order and that in between each step, we do proper hand hygiene.
Speaker: I can't overemphasize how much that would help if everybody did it the right way.
Speaker: And I do believe that sometimes simple interventions done well have the greatest impact on very complex problems.
Speaker: And that is something that I think a lot of people
Speaker: whether they believe it or not, don't actually act like they do.
Speaker: And the final question I usually ask my audience, my listeners, sorry, is what would they want everybody in the audience to know?
Speaker: And I think that it would be that in this situation, calmness is contagious, that as bedside clinicians, we are leaders for our teams, and that we should take a deep breath, pause, make sure everybody is safe,
Speaker: and really show people the way forward.
Speaker: It's the only way that we're gonna get over this and future challenges in healthcare.
Speaker: And I think it's an opportunity for clinicians to be leaders at the bedside and really make a difference.
Speaker: I look forward to talking with more guests in the upcoming weeks.
Speaker: And thank you for listening to the podcast.
Speaker: If you find this useful, please share it with others.
Speaker: Thank you very much.
Speaker: Stay safe.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
