How to ventilate the intubated COVID patient? Reviewed outcomes of first 9 patient today with my group. Still early days, but initial outcomes promising (6/9 extubated). Some thoughts on (limited) experiences thus far...(1/6)

First, these patients have pseudoARDS (not ARDS). They *are* recruitable, but this requires APRV and lots of patience (6-12 hours). I wonder if the concept that they aren't recruitable stems from insufficiently long trials of recruitment.
https://emcrit.org/pulmcrit/pseudoards/ (2/6)

COVID doesn't cause ARDS, so evidence about ARDS doesn't apply. For example, I worry that early proning (often with paralysis) may cause iatrogenesis (e.g., myopathy, delirium, delayed mobilization). Proning *will* help recruit lung tissue, but there are easier ways...(3/6)

specifically, with front-line APRV (*before* vent-induced lung damage has occured) the FiO2 requirement usually drops substantially. This suggests that atelectasis is a significant component of the physiology, as discussed earlier (4/6)

more on an "open lung" strategy using APRV as a primary ventilator modality:

fresh podcast by Weingart & Habashi:
https://emcrit.org/emcrit/aprv-primer/

nuts & bolts guide for ARDS in COVID:
https://emcrit.org/pulmcrit/aprv-covid/ (5/6)

the concept of using volume-cycled ventilation with *low* PEEP has become popular recently. This threatens to allow the lung to de-recruit, leading to atelectotrauma (repeated opening/closing of alveoli). Over time, this might cause lung injury and lead to legit ARDS. (6/6)