February FY21

[kristenhorsman]

The journal club this month is presented by Kristen Horsman. The article is titled Mechanical Ventilatory Support: What Every Anesthesia Provider Should Know in the Midst of a Respiratory Viral Pandemic and Beyond.

The article is attached to the email sent out. 

Please answer the following 2 questions:
1. Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients? What are suggestions to improve oxygenation in this patient population?

2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?

[Dahlia Rouchon, CRNA]

What a great and relevant article! Thank you Kristen. In response to your questions:
1. Recruitment breaths to improve oxygenation is not recommended in severe ARDS. As it mentions it can dangerous, decrease venous return, cause severe hypotension, decrease alveolar ventilation and lead to respiratory acidosis. It noted it gives transient increase in oxygenation but without change in outcome. The routine use, therefore is not recommended per the article.
2. Working as a RT during the spring COVID crisis was a sobering, challenging, and eye opening experience. The degree of respiratory disease managed was unlike anything I've seen in my career as a CRNA. To have PIP of 40s on a regular basis for the most ill, and trying to titrate this down to a safe low 30s was difficult to say the least. Or having a PaCO2 higher than PaO2 patient due to permissive hypercapnia was distressing to see; how to improve this ventilation? What worked, was prone positioning (for those not too ill to do so) and advocating to keep prone as inevitably supine positioning worsened the sickest patients which could take 2 days to recover. Doing the RT driving pressure protocol to find the best ventilation limits for patients. The calculation took into account starting plateau pressure and incrementally increasing PEEP to obtain the median plateau pressure (this median plateau pressure is the driving pressure). If patients were hemodynamically stable during the process, SpO2 improved, and ABGs improved, we used this new mode of ventilation. Using lower TV starting at 5cc/kg to decrease lung injury helped. NO was most helpful when DP limits were reached and patients could not be ventilated. No was especially needed with trach patients as they could not be proned. Chest tube placement when flash pulmonary edema occurred due to ventilator injuries was helpful. Increasing in norepi gtts when needing to manually ventilate a patient if using the ventilator did not improve ventilation just prior to cardiac arrest.
What didn't work was frequently changing lung modes of ventilation by changeover of staff intensivist to improve ventilation which ultimately brought the patient back to the original mode of ventilation used the week before. Supinating patients when the patient was prone too early was detrimental. Running frequent ABGs to immediately evaluate ventilation changes was paramount. Thorough staff handoff report to alert what interventions were made, what worked and didnt' work was critical. Using the team approach to call in expertise of the RT and those with advanced experience to help with especially difficult cases made a great difference.
Advice I would provide is use of albuterol as these patients are frequently bronchospastic, suctioning with bullets as their mucous is thick and tenacious, having vasopressors/gtts ready as they are often hemodynamically unstable. Consider active infection in outpatient settings of COVID+ even if noting a negative COVID test, clear lung fields and patients deny active infection if patient requires double anesthetics to stay anesthetized (high dose IA and high dose TIVA) and expect laryngospasm with difficult prolonged 45 minute wakeups with emergence bronchospasms. This same patient may later truthfully report had been exposed to URI in household before surgery. COVID patients metabolize anesthetics and muscle relaxants unusually quickly. Utilize higher PEEP 6-8 and lower TVs.

[clawry]

1. Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients? What are suggestions to improve oxygenation in this patient population?

Recruitment breaths are not suggested in covid 19 patients with ARDS due to hemodynamic instability including hypotension. Most of these patients ae already on vasopressor infusions and recruitment maneuvers could be detrimental. Suggestions to improve oxygenation in these patients are using lower tidal volumes, PEEP, nitric oxide, and proning.


2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?

I worked at the bedside on Nelson 5 with covid patients. Proning and nitric oxide seemed to have the most beneficial effects in the cases that I dealt with. The problem was he aftermath when we had to supinate the patients. The most critical patients on nitric oxide who were already proned with low tidal volumes and high PEEP did not tolerate being supinated. I remember several nights coming in to a patient who had just been supinated at change of shift. We would end up proning again shortly after coming on shift which takes up a lot of resources including RT, bedside RN's, PT if available, and 2 to 3 other people. It was very time consuming. Patients had a lot of facial breakdown from being proned for prolonged periods even with turning every 4 hours. I would follow the ARDSnet guidelines if you are caring for a critically ill covid 19 patient in the OR. I am going to be caring for a covid recovered patient in the OR tomorrow. I will be keeping all of these strategies in mind as I care for this patient who just had covid in December! 

[kels]

Recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressure is not suggested to improve oxygenation in the Covid- 19 patients . Proning and lower tidal volumes are more helpful with oxygenation .

When I was redeployed I worked as an ICU nurse. Putting a ventilated Pt in the prone positioned seemed to work . However, more times than not when putting these pt s back in the supine position resulted in poor saturations and re= proning . My advice , when caring for the prone ventilated pt one must always think about skin care, more importantly preventing skin breakdown.

[Anne McNulty CRNA]

I did not work as a respiratory therapist caring for covid pts. I did work as an ICU nurse in the 70's and 80's before most of you were born. In the decade of the 70's ARDS was referred to as "Shock Lung" The obesity epidemic was not in existence and most pts were given TV of 10-15 cc per kg. I can recall in the past using PEEP as high as 50 CM. Pneumo thorax was common. Jet ventilation did exist in the 70"s . By the end of the 80-'s rotating trauma beds were very common The prone position was beginning to be used in ICUs. We have come a very long way. Recruitment breaths are maneuvers that are more damaging than beneficial . Many anesthesia attendings at JHU have always encouraged these maneuvers. In the present time , I place my morbidly obese patient on 10-15 cm PEEP and do not receive negative comments. I enjoyed this article and the anecdotal revelations of my colleagues as respiratory therapists.

[nanci]

1. Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients? What are suggestions to improve oxygenation in this patient population?



2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?

[Jessica Hadley]

1. Recruitment breaths are not recommended to increase oxygenation in the COVID-19 patient as prolonged periods of increased pressure can lead to hypotension and decreased venous return. This can be dramatic in the critically ill patient.

2. I worked as a bedside ICU nurse last spring and can echo others experience; proning and peep seemed to be the most beneficial things for the acute ARDS people were experiencing. I distinctly recall one of my first days taking care of a patient who with the slightest turn was desating to the 70's. When we decided to prone him is oxygenation immediately and significantly improved.

[Shannon Segres Yorkman]

1. Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients? What are suggestions to improve oxygenation in this patient population?

Recruitment breaths with high volumes are not recommended. As stated previously, proning patients have proven to be most beneficial. Early intubation of Covid-19 patients was reported to help at the start of the pandemic. I am not certain if that is still in favor.

2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?

I did not float to the ICUs, but I did serve as a member of the airway team called to the floors to intubate Covid-19 patients. My advice for my colleagues that may care for Covid-19 patients over the next few months is SELF-CARE. When I would go to the those units; I liked to talk to the providers of these patients and it was disheartening. Caring for Covid-19 patients can be very hard mentally and emotionally. Witnessing my husband work on these units; I noticed the toll that it took on him. The shifts are long and grueling, and as nurses we tend to suck it up and neglect our personal health. He worked on a Covid-19 unit and the unit has seen tremendous RN turnover because of the grueling work that is required, and the Hospital’s neglect in compensating / incentivizing for the work that was being done. I would also advise journaling one’s experiences and possibly publishing one’s experience in a journal or book. The “inside story” of the pandemic is sure to be well received by the public.

[Jennifer Hannon]

Recruitment breaths are not recommended to improve oxygenation in the Covid19 patients . Proning and lower tidal volumes are more helpful with oxygenation .

I have enjoyed reading colleagues experiences during redeployment. My cardiologist put me out on leave for safety in March/April when not much was known about the virus, and my guilt and m love for friends caused me to send goodies and gifts to the units I saw CRNAs posting extra time in on Slack.

[katya]

1. Recruitment breaths are not recommended in covid 19 patients with ARDS due to hemodynamic instability including hypotension. Most of these patients ae already on vasopressors infusions and recruitment maneuvers could be detrimental. To improve oxygenation in these patients can be done by using ARDS protocol with lower TV, prone positioning and low PEEP.
2. I was not rotated to work ICU, but I am grateful that everyone came back to ORs and thank you for your extraordinary work and stories.

[Soo-Ok Kim]

1.Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients?
Not recommended in COVID-19 pt.
What are suggestions to improve oxygenation in this patient population?
Prone positioning and low tidal volume with permissive hypercapnea are the recommended method to decrease lung injury and to improve oxygenation.

2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?
I was a RT in PICU while PICU RT was deployed to take care of COVID pt.
I gained the perspectives of what RT does on daily basis and appreciate their contribution in COVID pt and ICU pt.

[aileenm4]

per this article, recruitment breaths are not reccommended and may be harmful, the prone positioning and lung protective ventilator settings are helpful, also sedation and or paralysis as needed for patients to tolerate the vent and not fight the settings

I was redeployed to the PICU as a RT adjunt provider. The pediatric population did not have as many ICU admissions, pedaitric patients even with MIS-C were treated with high flow nasal cannula and IV medications. I did not have any adult ICU COVID experience.

[Ben Waldbaum]

1. Are recruitment breaths, where the lung is subjected to prolonged periods of continuous positive airway pressures, suggested to improve oxygenation in Covid-19 patients? What are suggestions to improve oxygenation in this patient population?
not recommended
low tidal volume, prone, recommended

2. Please share any anecdotal experiences regarding Covid-19 patients you cared for as bedside RNs, respiratory therapists or in the OR as anesthetists. What worked? What didn't work? Any advice for your colleagues that may care for Covid-19 patients over the next few months?
nothing particular

[Tracey Trainum]

Question 1:

Recruitment breaths are not recommended as a strategy to improve oxygenation in Covid-19 patients. Recruitment maneuvers have been shown to only transiently increase oxygenation without changing outcomes. The process of mechanical ventilation itself can incite or worsen lung injury. Recruitment maneuvers in ARDS/Covid-19 patients can be "dangerous" secondary to increases in intrathoracic pressure leading to decreased venous return which then can lead to hypotension and a decrease in alveolar ventilation/respiratory acidosis. Instead, lung protective strategies are recommended. These include: prone positioning, TV 6-8 cc/kg, PaO2 50-80 mmHg, SpO2 89-95, minimum peep, Plateau P < 30 mmHg, and permissive hypercapnia (pH > 7.15)

Question 2:

I do not have any direct care experience with Covid-19 patients. However, from colleague reports I have heard the fast rate of decompensation in these patients is quite alarming. I have also heard they can have unexpectedly complicated airways from apparent swelling and inflammatory processes. 

[Christine Velarde]

1.Recruitment breaths are not recommended as a strategy improve oxygenation in COVID patients. Prone position, Tidal volumes 6cc/kg,PO 50-80mmHg Spo2 89-95% plateau p<30 mmhg and permissive hypercapnia pH> 7.15) are more suggestive strategies to improve oxygenation in COVID-19 patients.

2.Caring for patients in the ICU with COVID-19 was an eye opener. I got to see how hard the ICU team worked to give the best care for critically ill patients. Often the team would prone the patient with all the lines/drips/continuous hemodialysis . Compassion was given to those who could not have love ones visit them. Tireless work with minimal breaks. The ICU team deserves much credit to help establish guidelines to help COVID patients get well and go home.