Management of COVID-19 Respiratory Distress @JAMA_current: 4 most noteworthy points with some thoughts (1/9):

"Types L and H are the conceptual extremes of a spectrum that includes intermediate stages, in which their characteristics may overlap" https://jamanetwork.com/journals/jama/fullarticle/2765302

Finally some common sense. Not much to add to this one. Thoughts by @ogi_gajic @MiscSusan @robertpdickson and @iwashyna (2/9)

"Patients with type L, (normal compliance) accept larger tidal volumes (7-8 mL/kg IBW) without worsening the risk of VILI"

Some are vehemently opposed to this ( @MGHMedicine
's FLARE). However, there might be some evidence that supports this... (3/9)

PReVENT (not ARDS, nl compliance) showed TV (10 cc/kg) made no difference. ARMA showed mortality in ARDS with TV of 6 cc/kg vs 12 cc/kg. However, no difference vs excluded pts (with mean TV of 9 cc/kg). Also TV seemed to BENEFIT pts w nl compliance (sub-group) (4/9)

This doesn't mean that its always ok to ventilate normal compliance pts with 10 cc/kg. But definitely care can be individualised; If going higher than 6 cc/kg is expected to bring benefit, it should not be viewed as a magic evil threshold (5/9) https://twitter.com/phlegmfighter/status/1249343854014332936?s=20

"The clinician’s 1st response, boosting FIO2, may indeed prove effective early on. Noninvasive support (eg, high-flow nasal O2, CPAP, Bi-PAP) may stabilize the clinical course in mild cases, provided that the patient does not exert excessive inspiratory efforts" (6/9)

Yes, yes, yes! Awake proning and HFNC might help avoid early intubation. Excessive inspiratory effort on the other hand could lead to P-SILI and be detrimental. Tolerate the happy patient, watch for increased EFFORT. Discussed at length previously: (7/9) https://twitter.com/ArgaizR/status/1250620308903669760?s=20

"Raising mean transpulmonary pressures by higher PEEP or inspiratory-expiratory ratio inversion accentuates stresses on highly permeable microvessels and compromising CO2 exchange without the benefit of widespread recruitment of functional lung units." (8/9)

This is a direct criticism of APRV for "L-Phenotype". The problem lies with the definition of "recruitability". This has already been covered at length by @PulmCrit https://twitter.com/airwaycam/status/1251637700253421572?s=20 (9/9)