EM:RAP 2020 April 3rd Breaking News - Airway Management in COVID-19

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Benjamin L. -

Has anyone read about possible Ivermectin trials on COVID19? In short, researchers in Australia are showing a 5000 fold reduction in-vitro of SARS-CoV-2 in 48 hours. Could be interesting, thoughts?

Alfred S., M.D. -

That is one I have not heard of yet. As hopeful as some of these in-vitro studies appear, I am always disappointed when they don't work in clinical practice.
It would be great if it does work.

Al

Mel H. -

Here is that paper - I am with Al - hope it works but this was just invitro study - https://www.sciencedirect.com/science/article/pii/S0166354220302011?via%3Dihub

Benjamin L. -

Thank you all for your prompt responses. I love the show!

Carson P. -

Will you be able to make a summary of this update. It was perhaps the most useful covid update I've heard. Thank you for your help!

Alfred S., M.D. -

Dr. Whittle has an article in press in Journal of American College of Emergency Physicians which is basically a summary of this. Also, the EmRAP Core Pendium Chapter has a nice summary of this material.

Sunil M. -

Just looking for clarity as some sources are recommending HFNC and Non-rebreathers only be used in negative pressure rooms (except for non-rebreathers/venturi with viral filter capability). These are at a premium in many locations. With the limited dispersion of aerosol particles described, is it safe for health care workers to use these devices in closed door environments without negative pressure? What about non-closed door environments?

Jessica W., MD -

Carson, if you would like to send an email to me at Jessica.Whittle@erlanger.edu, I'd be happy to forward you a pre-publication copy of our paper. Also, the ACEP site has some focused reviews as well

Jessica W., MD -

Sunil -

Great question. There is a preliminary article coming out in CHEST this week showing that vapotherm high flow system (at full flow) with a regular surgical mask disperses aerosol to the same level as normal tidal breathing. Work on the Fisher-Pakyel system shows dispersal from 4.8cm - 17cm depending on flow. (to put in context, 1L NC disperses to 30cm)

So, of course my recommendation is that all COVID patients be in a negative pressure room when available. When not available, I believe patients on high flow therapies are no more infectious than those on nasal cannula - and with a mask over them, they are less infection than a nasal cannula and equivalent to tidal breathing. I think treating them in a room with a door is fine.

Don't forget to try to get them to roll onto their stomachs as proving seem to help!

Lisa W. -

Can you provide the citation/link for the CHEST article?

Rachael G. -

Could you please provide the full reference for CHEST Vapotherm high flow article and data for the Fisher-paykel system dispersal?

Alfred S., M.D. -

When placing a patient in the prone position, put their face in one those horseshoe shaped neck pillows that people use when sleeping on planes. This allow the patient to lay face down while still keeping their face's elevated and tubing to run up to the patient.

Sean G., M.D. -

The real question...which was not addressed here, was what percentage of people placed on Bipap or similar do not go on to intubation?

Sean G., M.D. -

Also can we stop quoting the WHO? They have colluded w the CCP to contribute to worsening of this Pandemic. I also feel we need to hold the CDC accountable for their misinformation.
1. Lack of testing....this resulted in a far worse Pandemic both in health effects as well as Economic.
2.
Masks dont work for the general public....they held this position for about 8 weeks which contributed to the spread of disease no doubt. Now that the data is impossible to avoid they are saying what they should have said day 1...."Of course masks work! Unfortunately we, and most hospitals have failed to properly stock...so we have a shortage....please dont stock pile pro masks our healthcare workers need them...but here is a link to a video to help you fashion a home made one which should work well when u must go out to shop"
Had they said this I believe most citizens would have worn a home made mask...they also would have shamed those who were hoarding pro style masks...disease propagation would have been limited. There was absolutely no scientific break ths this past week leading to their position change...it was simply they could not keep the lie going anymore.
4. If u are not showing symptoms you are not infectious...they held this one for a while too despite a plethora of evidence to the contrary...Along with worsening the situation for t6he general public...it also greatly increased transmission no doubt in our healthcare system where nurses and doctors were not wearing masks around people who were not coughing or with fever...This was a combination of 3 and 4.
When u lie...people stop trusting you. there was an interesting article many of us read(actually had read to us as children) It was titled " The boy who cried wolf" The conclusion of the article was "Dont lie...people will stop trusting you" Maybe these Health org leaders missed that one.
So does Bipap actually work or are we just again trying to cover for our vent shortage?

Jessica W., MD -

Here are the citations mentioned:

Leonard S, Atwood CW Jr, Walsh BK, DeBellis RJ, Dungan GC, Strasser W, Whittle JS, Preliminary Findings of Control of Dispersion of Aerosols and Droplets during High Velocity Nasal Insufflation Therapy Using a Simple Surgical Mask: Implications for High Flow Nasal Cannula, CHEST (2020), doi:

https://doi.org/10.1016/j.chest.2020.03.043.

Whittle, J.S., Pavlov, I., Sacchetti, A.D., Atwood, C. and Rosenberg, M.S. (2020), Respiratory Support for Adult Patients with COVID‐19. Ann. Emerg. Med.. Accepted Author Manuscript. doi:10.1002/emp2.12071

https://doi.org/10.1002/emp2.12071

Danish K, M.D. -

thank you so much. was looking for these.

Jessica W., MD -

Rachael:
The above two citations cover all three questions (the Respiratory Support article contains the numbers for the Fisher-Paykel system as well as the references for the original models)

Jessica W., MD -

Sean G:
I think this is a great question. Unfortunately, due to the fact this is an entirely new clinical entity and resources/ treatment patterns vary internationally, no one has very good data on this.

One critical care doctor from Italy said that maybe 25% of the severely hypoxic could be treated with NiPPV and avoid a vent (in the interview with JAMA editor - available on JAMA website). Data from China vary by province. Near Wuhan, NiPPV use is reported, but it is unclear as to whether this was due to lack of available ventilators or because that was the intended treatment. Outside Wuhan, a neighboring province reported reducing mortality by 25% and vent use by half by using early and aggressive screening coupled with early and aggressive high flow or NiPPV with proning. These data are all preliminary and difficult to interpret when methods of reporting of cases/ mortality may not always be identical in different countries.

https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00650-2

We do know that high flow compared to NiPPV reduces mortality (FLORALI study) in pneumonia, and that high flow is effective and reduces mortality for type 1 respiratory failure. This data is reviewed in the manuscript I mentioned above : https://doi.org/10.1002/emp2.12071

Stephen A., M.D. -

Any thoughts on SVNs. How much do these contribute to aerosolization and any tricks to minimize dispersion.

Jessica W., MD -

Great point - nebulizers are one of the most dangerous things out there right now. We have essentially banned them in our hospital. The have a known dispersal distance of close to a meter (80cm) with no good way to contain it. In SARS 2003, they were specifically linked to nosocomial and healthcare worker infections. References/ data in the manuscripts listed above.

Stephen A., M.D. -

What are you recommending for our asthmatics and COPD exacerbations? Some of us don't have negative pressure rooms. It's even more difficult for our pre-hospital folks.

Jessica W., MD -

There is a good discussion with several protocols on the ACEP Engaged forum. But essentially 4-8 puffs of an MDI is equal to a 15 min (2.5 mg neb). Use all the adjuncts including magnesium, etc and consider IM epi for rescue

Alfred S., M.D. -

We are reverting back to the 1970's and leading with Epinephrine. Younger patients (<60) are getting IM epinephrine (0.5mg) up to three doses and PO Prednisone 60mg. Older patients are getting terbutaline (0.25mg SQ) plus Prednisone. It is very unsettling to the nurses and Health Care Providers under 60 years of age to hear these recommendations, but the reality is, these approaches were very safe back in the day. And no these patients do not need to be on a heart monitor.

I agree with Jessica, if we have MDI's we will use them.

Robert B., Dr -

What about nebulized epinephrine for croup? Is there an alternative? What are your thoughts?
Cheers
Dr Rob Bonnin (Cairns Australia)

Robert B., Dr -

I found an interesting variation on HFNC augmented by "the double-trunk mask" in one of David Hui paper's references. "The Double-Trunk Mask Improves Oxygenation During High-Flow Nasal Cannula Therapy for Acute Hypoxemic Respiratory Failure
Frédéric Duprez, Arnaud Bruyneel, Shahram Machayekhi, Marie Droguet, Yves Bouckaert, Serge Brimioulle, Gregory Cuvelier and Gregory Reychler
Respiratory Care August 2019, 64 (8) 908-914; DOI: https://doi.org/10.4187/respcare.06520"
In this small group of patients (15) treated with HFNC there was significant improve oxygenation with NFNC when used in combination with the double trunk as compared HFNC by itself. I am not expert in this field but the double-trunk arrangement would appear to act as an effective diffuser reducing velocity of expired gases and potentially reducing aerosolization of covid-19. Also a very cheap low tech means to enhance oxygenation. Interested in your thoughts.
Cheers Rob

This is the abstract:
"BACKGROUND
High-flow nasal cannula (HFNC) oxygen therapy is used to deliver an FIO2 from 0.21 to 1.0. The double-trunk mask (DTM) is a device designed to increase the FIO2 in patients with a high inspiratory flow demand. The aim of our study was to evaluate the effect of DTM in hypoxemic subjects already receiving HFNC.
METHODS
We report a prospective multi-center crossover pilot study including 15 subjects treated with HFNC for acute hypoxemic respiratory failure. Measurements were performed at the end of 30-min periods with HFNC only, with HFNC + DTM, and again with HFNC only.
RESULTS
Compared with HFNC alone, HFNC + DTM increased PaO2 from 68 ± 14 mm Hg to 85 ± 22 mm Hg (P < .001) and did not affect PaCO2 (P = .18). In the 11 responders, the PaO2 increased from 63 ± 12 mm Hg to 88 ± 23 mm Hg (P < .001). No complications were reported during DTM use.
CONCLUSION
In subjects receiving oxygen via HFNC, the addition of the DTM over the HFNC increased PaO2 without changing the PaCO2."

Jessica W., MD -

HI - as for alternatives for croup,

I am not sure that I have much more to offer beyond the things mentioned above. I treat mostly adults. Al's post above has some great suggestions. Data from the newer anaphylaxis studies shows IM epi is safe even for those with underlying cardiac disease and older than we thought.

As for your second question about the double trunk mask - I have no experience. I have run the idea past several colleagues and they don't have any ideas either. We would all be interested in more data if you come across any!

Alfred S., M.D. -

Robert:

I cannot find the article your are referencing. I can find the abstract with the URL, but cannot find the actual article. I have the respiratory folks looking for it. I am interested in seeing this double mask set up.

Regarding croup. There is no reason you cannot nebulize any medication in a patient, even without a negative pressure room if you are certain they do not have a SARS-CoV-2 infection. A 10 month old infant with stridor and a croupy cough is extremely unlikely to have COVID-19 disease and I would not hesitate to nebulize either decadron or epinephrine if indicated in that child. You are likely to aerosolize some parainfluenza virus in the process, even when delivering the nebulized medication by mask, but this does not seem to present that much of an actual risk to other patients in the department. If this were the case we would have witnessed clusters of return visits from children in the ED with other problems when treated in proximity to the child with the epinephrine nebulizer.

Because asthma is a lower respiratory problem and wheezing is associated with SARS-CoV-2 infections, it is prudent not to nebulize them because you cannot be certain at all that they do not have COVID-19 disease.

Stephen O. -

NC on 4-6 liters 30-40cm
venturi mask 40cm
NRB 15 liters "a few cm"
NIPPV 100cm with very high risk of transmission to providers (similar to intubation)
HFNC 5-17cm

Jessica W., MD -

This is correct - there is a figure showing this summary with complete flow data and references in the article:
(for NRBM it was <10cm as that was the lower limit of detection)
NiPPV - 95cm in the event of mask movement or leak (helmets rarely leak and do so only to 2-3cm in models)
HFNC - 4.8cm at with the flow rates typical of diseased lungs, up to 17cm with healthy forceful lungs

Whittle, J.S., Pavlov, I., Sacchetti, A.D., Atwood, C. and Rosenberg, M.S. (2020), Respiratory Support for Adult Patients with COVID‐19. Ann. Emerg. Med.. Accepted Author Manuscript. doi:10.1002/emp2.12071

https://doi.org/10.1002/emp2.12071

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EM:RAP 2020 April 3rd Breaking News Full episode audio for MD edition 13:59 min - 20 MB - M4ASSC-COVID19-Critical-Care-Guidelines 2 MB - PDF