1/9- Just coming off a week on call in the MSICU at TGH with @ecgoligher. Started the week with 6 COVID+ patients and we transferred in 12 more, mostly for worsening respiratory failure (so not a random sample of COVID pneumonia). All intubated; 6 cannulated for VV-ECMO.

2/9- Reflections on the ventilatory management of these patients. The patients we transferred in typically had the same story – sick at home/ward for a week, on the vent for about a week and now worsening. Mostly men with hypertension +/- other components of metabolic syndrome.

3/9-Most had did have severe hypoxemia out of keeping with CXR appearance – though CXRs were not normal by any stretch. Huge ventilatory demands – ventilatory ratios above 3, some of the highest I’ve seen.

4/9- Our new patients all arrived sedated and paralyzed. We continued to prone those with P/F<120 and driving pressures above 12. Attempted to stop paralysis daily in all the rest – mostly successful… but a few with brittle oxygenation that needed restarts

5/9- Next step was weaning sedation – often more complicated with agitation and lots of coughing requiring weaning of propofol over a few days with ongoing fentanyl and addition of precedex and/or antipsychotics – keeping an eye on HR and QT of course.

6/9- We proned patients even if they didn’t have a fantastic oxygenation response thinking that this would still distribute the strain more homogeneously across the lung. Refractory hypoxemia or high delta P despite lowest Vt we could get away with were triggers for VV-ECMO

7/9- Most arrived with high FiO2 (0.7-0.9) and high PEEP (16-20 cmH2O) – higher than we see usually. CXRs did not suggest tiny baby lungs so we usually tried lower PEEP by 4-6 cmH2O – with variable results – reinforces the need for individualized PEEP as in all ARDS patients.

8/9- Bottomline – these patients are clinically challenging – our usual pattern recognition approach to ventilation does not necessarily apply. But going back to first principles allows one to build a rational strategy for each patient.

9/9- Avoid volutrauma – VT 6ml/kg PBW, driving pressure <14; adjust PEEP considering oxygenation and hemodynamics; monitor effort to ensure P-SILI is not a contributor and ideally maintain normal diaphragm work. Proning then ECMO if failing. Not so different from PMID: 30642778