Coronavirus (COVID-19) Update: Critical Care Management

Noninvasive ventilation (NIV) , working with dying patients’ families, use of experimental therapies, and more. Derek Angus MD, MPH, FRCP, Distinguished Professor and Chair of Critical Care Medicine at the University of Pittsburgh, provides a COVID-19 ICU management update. Originally broadcast on Wednesday, April 1, 2020 at 13:00 CST (GMT-05:00).

Topics discussed in this interview:
0:00 Introduction

2:00 Say you have 100 patients come into the hospital with COVID-19. It looks like about a third end up in the intensive care unit. How do they do once they're in the intensive care unit?

7:00 There's been some tension about early intubation versus waiting. Do you want to comment on that or just not enough information?

8:16 There are reports of people who are developing acute respiratory distress syndrome (ARDS) and deteriorating very quickly. Do you have a sense of that in your ICU?

9:56 There's been some reports that for the people who get intubated they appear to stay on mechanical ventilation for a longer period of time than people's other experience with ARDS but again, this is observational information.

12:52 Case-fatality once you're intubated is high. From looking at the various reports, talking to your colleagues, do you have a sense of what it is?

15:05 As someone who runs a lot of ICUs, what's your greatest fear?

17:48 What's your sense of the clinical trials? Where will they be successful? Should they be tried in very sick people or is the goal to try some of them in less sick people to prevent those people from needing the intensive care unit?

22:27 Do you have a sense - is it going to be the antivirals, is it going to be this so-called cytokine storm that we can intervene with, will it be chloroquine? Do your instincts tell you that there is going to be a big gain with one of these new therapies?

26:45 Do you understand the exuberance around chloroquine?

29:00 Are there any clinical trials focused on preventing mildly ill patients from needing ICU care or have most of them been focused on the more ill patients?

32:10 Visitation is remarkably limited and their loved ones are dying and are going to die. Either they're on a ventilator or they've been appropriately extubated to spend their last few hours in comfort. How do you imagine that playing out in the US?

38:39 How soon do you think we'll get results from the randomized trials?

40:58 What is the primary outcome in most of the trials?

41:52 Would you use one ventilator for two patients if ventilators are scarce?

42:45 What do you think the 900,000 physicians who aren't intensivists need to know?

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[sandyb]

Such a great interviewer, thank you so much, Dr.Bauchner! Great interview series! Thank you, Dr. Angus for such valuable information.

[sandyb]

What about hydrothermal therapy used to great effect during 1918 pandemic in sanatoriums?

[islandbirdw]

Proning, low tidal volume & PEEP to help the patients with mechanical ventilation and to improve outcomes. Appears to be needed to re-inflate and recruit the alveoli that need to be re-recruited.
I wonder if there may be a wayward child

[gregbingaman]

For coverage in the tiered model or tele model don't forget about utilization of acute care trained nurse practitioners.

[eduardohoover]

What about using prone with a degree of trendelenberg positioning in the ARDS patient? Would this enhance the oxygen level?

[AuerbachPlexus]

Which N95 does he use with that goatee?

[SteezyHG]

Any knowledge yet of the long term lung damage? And respiratory capacity afterwards?

[internationaltax]

Please widely disseminate Dr. Angus' comments on organizing, about 45 min. into video. This is the strategy used in large public accounting firms, and works well: Pyramid structure, with quasi-expert good leaders at top and multiple readily available expert consultants to advise. His caveat just thereafter is well noted: you need someone who can intuitively detect and anticipate when the patient is on the verge of serious problems. Thanks for great vid.

[dawnguritzky]

I was just going to ask about the use of CPAP usage, but with monitoring

[newhorizon]

Dr.'s hair keeps me mesmerized....

[judiemaguteledge]

Love a doc who speaks doesn't JAMA get more views.

[SenseMed]

Bravo to you both. Phenomenal overview

[bibego]

About the paper with Covid19 1500 patients, where is it published?

[sandyb]

Visitation should not be allowed in ICU during a pandemic. It is a sad reality of an already horrendous situation. To use valuable ppe that could save a healthcare workers life is unacceptable. These patients are sedated and relatives must understand that the risk is too high. Until you are in the war that Italy is currently enduring, you will not be even able to comprehend the severity of it. Were parents of critical soldiers during WW1 or WW2 airlifted in to frontline battlefields to say 'goodbye' to their loved ones? This is a very serious war, and while unfortunate, we must all realize this.

[luminyam]

The reason ppl are so excited about the malaria drug is bc you don't have healthcare in the USA. It is not popular here in Canada, where we follow science.

[susane]

Please address latest Medscape article “Toilets May Spread Covid-19” about potential spread of covid via virus found in stool and a viral flume when toilets are flushed.
***
Does CPAP/BIPAP aerosolize virus more easily than ventilators??
***
Could lack of vitamin D, especially in African-Americans, be a factor in higher mortality? Considering relationship between vitamin D and respiratory function.
**
Discussion of viral load and severity of covid infections.

[louisebrigidobrien]

Proning in awake patients definitely works! Please use, referred to as 'self proning'

[roxannetyroch]

I am surprised at your ideas at how to manage the COVID situation in the outpatient setting. Please have more respect for the roles that outpatient physicians have in this pandemic.

[haze]

Hydroxychloroquine, azathioprine, and zinc show a lot of promise in keeping infected patients OFF of ventilators. Unfortunately, some of these drug trials are only being used on intubated patients who are dying. And if it doesn't work in those dire circumstances, the medical community simply announces that the treatment doesn't work at all.

[Tom-ktlu]

I predict this pandemic will give rise to much ingenuity.