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This episode continues on from last time's talk by Sara Crager on Right Ventricular Failure. This is a Q&A session with a focus on inhaled pulmonary vasodilators.

Nitric Oxide

Sara likes it through ETT or Hi-Flo NC (can also be done through BIPAP)

Start at 20 ppm

See results within 5-10 minutes

Monitor with CVP

Problems

* Nitric Dioxide (NO2) may be formed which can lead to pulmonary edema or even alveolar hemorrhage.

* MetHb can be formed and some people do routine monitoring for this dyshemoglobinemia.

Additional Resources

* PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?

* Review Article on Inhaled NO

 

Epoprostenol (Flolan)

May be more complicated to set-up

go back to marker 5

Epoprostenol @ 0.05 mcg/kg/min

Must have filters on the circuit

* Review Article on Inhaled EpoProst

 

Milrinone

Get the vial, you want 1 mg/ml with 15 mls in vial

5 ml (5 mg) q 6 hours (According to Dr. Crager--may be more frequent if symptoms rebound (down to q 3 hrs))

Ideally use ultrasonic nebulizer

onset ~15 minutes

Must have filters on circuit

LVOTO & RVOTO contraindication for the milrinone

 

respigard!!!

aeroneb pro

must have filters on vent

from Andre Denault Lecture

Additional Resources

* Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

* A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

 

Intratracheal Milrinone Bolus for a Crashing Patient

50-80 mcg/kg or 5 mg (1/2 a bolus is also used by some)

onset 4-5 minutes

from the amazing Hospitalist & the Resuscitationist Lecture 2019 by Andre Denault

 

Nitro

Need conc. of 1 mg/ml (standard bottle is 200 mcg/ml)

Doses in studies range from 2.5-25 mcg/kg/min for 10 minutes or 50 ug/kg total given over 8 minutes (perhaps easiest to put 4-5 mg in neb and let it run)

* PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Photo by Valeriia Bugaiova on Unsplash

Now on to the Podcast...

We did an amazing episode on EMCrit with Susan Wilcox on Right Heart Failure. However, this oft neglected ventricle deserves even more coverage giving how pesky it can be when it fails. So we brought Sara Crager, MD to Stony Brook to give Grand Rounds. You are going to love this lecture. Part 2 is a Q&A and will be released as a separate episode.

 

This is an embedded Microsoft Office presentation, powered by Office.

 

Now on to the Podcast...

Participants

Josh Farkas

Rory Spiegel

Cameron Kyle-Sidell

Scott Weingart

COVID Low Low PEEP Scale

not for clinical use, just a thought provoker

Personalized PEEP

* [Crit Care 2019;23:412] and

* [Respiratory Care 2020;65(5):583] and

* [Intens Care Med Experimental 2017;5:8]

* Personalize PEEP to Minimize VILI

Now on to the Wee...

Insane, Granular Intubating-Monkey Checklist

* Insane Granular Monkey Tube Checklist 2020-04-13

COVID Awake Repositioning and Proning Protocol (CARP)

* See the CARP Post

Keep 'em from getting Intubated Flow (Adapted from Cam Kyle-Sidell's)

* COVID Oxygen Management Flowchart SDW edits

Now on to the Podcast...

Phillipe Rola convened a webinar on Respiratory Management of COVID19. The guests included:

Panelists:

* Dr. Laura V. Duggan MD FRCPC (Anesthesiology and Pediatrics), Associate Professor, Department of Anesthesiology and Pain Medicine, University of Ottawa, Canada @drlauraduggan. www.airwaycollaboration.org

* Dr. Marco Garrone, MD, ED doc from Mauriziano Ospedale, Torino, Italy. @drmarcogarrone.

* Dr. Cameron Kyle-Sidell, MD, ED-ICU, Maimonides Hospital, New York. @cameronks

* Dr. Josh Farkas, ICU, University of Vermont, Creator, The Internet Book of Critical Care (IBCC), @pulmcrit.

* Dr. Adam Thomas, ED doc & CC Fellow, University of British Columbia, co-author, The Internet Book of Critical Care, @adamdavidthomas.

* Dr. Philippe Rola, ICU, Santa Cabrini Hospital, Montreal, Quebec. @thinkingcc

* Dr. Rory Spiegel, ED-CC doc, Washington Hospital Center, Washington, DC. @emnerd

* Dr. Scott Weingart, ED-CC doc, Creator, emcrit.org, Stony Brook Hospital, New York. @emcrit

Program:

* HFNC & NIV – do we dare use them?

* when do we intubate?

* how do we ventilate? prone ventilation routine or rescue?

* Adjuncts: suction, bronchoscopy

* When do we wean?

* Q&A if time allows.

This is part 2 of the APRV - TCAV series. In part 1, I gave a primer on APRV. In this 2nd episode, I speak with the creator of the TCAV method of APRV, Nader Habashi.

Nader Habashi, MD, FACP, FCCP

Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA

Dr. Nader Habashi is a Professor of Medicine at the University of Maryland School of Medicine and the Medical Director of the Multi-trauma Critical Care Unit at the R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, USA. He also serves as the Medical Director for the Respiratory Therapy Department of the STC. Additionally, Dr. Habashi is the Medical Director for the Organ Procurement Organizations in Maryland (The Living Legacy Foundation) and Los Angeles, California (One Legacy). He is board certified in the areas of Internal Medicine, Critical Care Medicine, Pulmonary Medicine and Neuro Critical Care Medicine.

Dr. Habashi’s major study interests include alveolar mechanics and mechanical ventilation, mechanical breath profile and clinical management of organ donors. Dr. Habashi collaborates with Syracuse University Medical Center in large and small animal models.

COI: Dr Habashi reports presenting at conferences sponsored by or in part by Dräger Medical between 2010 and 2015 for which he received remuneration for honoraria and travel. He is also a founder of Intensive Care On-line Network (ICON) and presented webinars hosted by ICON between 2010 and 2015 and continues to present such webinars and assist clinicians with questions, without any remuneration received. Dr Habashi also reports that he has been issued 2 patents for a ventilation method related to initiating, managing, and/or weaning airway pressure release ventilation and controlling a ventilator in accordance with this method. To date, the patents have not been licensed to any manufacturer and no monetary gain has resulted from the patents.

Resolution: No specific companies were mentioned in the podcast. All topics were discussed generically.

APRV-TCAV Recruitment of Alveoli

Stuff Mentioned

* Physiology in Medicine: Understanding dynamic alveolar physiology to minimize ventilator-induced lung injury

APRV Set-Up at its Simplest

from the original description: Crit Care Med 1987;15(5):459

PV Curve

Setting Tlow

Study of APRV

* Zhou et al.

Theory/Physiology/Reviews of APRV

* 40635_2016_Article_85

* document

* Nieman2018StablizeaBrokenLung

* 180126.full

APRV Network

APRVnetwork.org

then click on banner for COVID19 rescue to get all of the documents mentioned

More Stuff

* broken lung

* APRV Evolution

More on EMCrit Site

* IBCC Chapter on APRV during COVID19

Now on to the Primer...

 

 

ESICM Webinar Mentioned

* ESICM Seminar on COVID Ventilation

Read this to See the Thoughts of Actual Smart People

* in ICM

M. Ramzy's Infographic on the Article

Subtypes of COVID

Mild

Silent Hypoxemia (can cause iatrogenic injury when patients are intubated in this phase)

Indolent- Fine then Not (Intubated or Not-Inflammatory Markers)

Hyperacute

 

Cytokine Storm

Hemophagocytic Lymphohistiocytosis (HLH) Overlap / DIC

 

PathoPhys

Loss of hypoxic vasoconstriction

Micro-thrombotic disease

 

Avoidance of Intubation

Tachypnea, hypoxemia, do not seem to be indication

Mental status, Increased Dyspnea, PaCO2 rising

 

Progression of Therapies

NC

Venti

NRB+NC

Hi Flo with Surg Mask

CPAP—must monitor for excessive WOB

 

Non-Intubated Proning

ask them to move

 

Run them Dry

but not too dry--must replace external and insensible losses or else badness ensues

 

How to not kill patients with Intubation

EMCrit Airway Page

 

How to Ventilate

High FiO2 Strategy—Normal Compliance Patients

8 ml/kg, high fiO2

keep checking Driving Press and Plat

Avoid the PEEP Tables

Driving Pressure <=15

Proning

 

Prost/NO

 

Low Compliance Patients

6 ml/kg

Conventional Low Vt PEEP Table

Driving Pressure > 15

APRV

works for either subtype

if experienced, should be dominant mode of ventilation

 

Other Meds

* Heparin

* Steroids

 

Here is the Video Version

Audio Version Here:

 

 

 

 

 

 

In many hospitals ventilators have become a scarce or non-existent resource in the face of the COVID19 pandemic. We need a ethical structure to allocate ventilators and other scarce resources:

Exclusion Criteria before Entry into Ventilator Allocation Strategies

* Swiss Intensive Care Society Guidelines

 

Reub's Adaptation of the NYC Vent Allocation Guideline

* Strayer Ventilator-Allocation-Protocol

* Original EMUpdates Post

* ECOG Calculator

Original NYC Vent Allocation Guidelines

* 2015 Update

 

Publications

* NEJM Allocating Vent Discussion

* NEJM Fair Allocation of Scarce Medical Resources in the Time of Covid-19

* JAMA White & Lo

* Requests for Potentially Inappropriate Treatments in Intensive Care Units

Forming a Rationing Team

* LitFL Post

Now on to the Podcast...

We need to swing the pendulum the other way...

Additional Stuff

* Cameron Kyle-Sidell, MD Video

* Chest PT

* Incentive Spirometry

* Gattinoni Article in the Blue Journal

* Recent Plea in Critical Care

Now on to the wee...