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Treating hypoxemia caused by COVID-19 with early intubation + high PEEP may hurt patients
"It seems to be some kind of attack on the capillary-alveolar interface combined with some kind of hemoglobinopathy that is something I have never seen."
https://thinkingcriticalcare.com/2020/03/28/covid-clinical-discussion-w-cameron-kyle-sidell-nyc-ed-icu-doc-in-the-trenches-foamed/ https://twitter.com/cameronks/status/1245311511649816576
"It seems to be some kind of attack on the capillary-alveolar interface combined with some kind of hemoglobinopathy that is something I have never seen."
https://thinkingcriticalcare.com/2020/03/28/covid-clinical-discussion-w-cameron-kyle-sidell-nyc-ed-icu-doc-in-the-trenches-foamed/ https://twitter.com/cameronks/status/1245311511649816576
Because COVID patients are showing the classic "ground glass" presentation on chest CTs that we associate with ARDS, we are treating them as per ARDS protocol: early intubation, positive pressure ventilation
However, COVID patients have hypoxemia (low blood oxygenation) & pulmonary hypertension WITHOUT DYSPNEA (difficulty breathing)
this is not ARDS
COVID Syndrome is a new phenomenon more akin to Decompression Sickness ("the Bends") or HAPE (High Altitude Pulmonary Edema)
this is not ARDS
COVID Syndrome is a new phenomenon more akin to Decompression Sickness ("the Bends") or HAPE (High Altitude Pulmonary Edema)
Patients need oxygen to treat hypoxemia, not positive pressure ventilation to treat respiratory failure
Putting patients on a vent with high PEEP (positive end-expiratory pressure) for an extended period may damage the lungs that hurts more than it helps
Putting patients on a vent with high PEEP (positive end-expiratory pressure) for an extended period may damage the lungs that hurts more than it helps
Instead, try to fix the hypoxemia itself with high-flow oxygen
Delay intubation longer than you'd expect!
Consider VV ECMO (veno-venous extracorporeal membrane oxygenation) if available
Delay intubation longer than you'd expect!
Consider VV ECMO (veno-venous extracorporeal membrane oxygenation) if available
Emerging Treatment Regime:
Intubate ONLY when A) 90% oxygen is required to achieve sats in the high 80s *AND* B) patients are showing signs of respiratory distress (anxiety, tachypnea)
Post-intubation, set PEEP low––to just above what it would be with high flow oxygen
Intubate ONLY when A) 90% oxygen is required to achieve sats in the high 80s *AND* B) patients are showing signs of respiratory distress (anxiety, tachypnea)
Post-intubation, set PEEP low––to just above what it would be with high flow oxygen
"I am in no way advocating to let people ride out at extremely low saturations. I just run into the quandary where I am quite sure that putting them on ventilator settings that are accepted & that I have been trained to do will possibly cause significant harm." - @cameronks
Dr. Cameron Kyle-Sidell, MD ( @cameronks) is an attending ED & Critical Care physician who runs the ICU at Maimonides hospital in NYC
These notes are taken from this clinical interview & discussion on March 28, 2020 https://thinkingcriticalcare.com/2020/03/28/covid-clinical-discussion-w-cameron-kyle-sidell-nyc-ed-icu-doc-in-the-trenches-foamed/
These notes are taken from this clinical interview & discussion on March 28, 2020 https://thinkingcriticalcare.com/2020/03/28/covid-clinical-discussion-w-cameron-kyle-sidell-nyc-ed-icu-doc-in-the-trenches-foamed/
This is the Italian paper he references in the interview: https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE
Video from @cameronks where he talks about this more: https://vimeo.com/402537849
I have done my best to accurately represent his words & his thinking
I myself am a retired NYC Paramedic who's treated 1000s of patients & intubated 100s. Now I am technology entrepreneur & investor in Silicon Valley.
I have share & promoted this thread for the public benefit
I myself am a retired NYC Paramedic who's treated 1000s of patients & intubated 100s. Now I am technology entrepreneur & investor in Silicon Valley.
I have share & promoted this thread for the public benefit
