COVID-19 Critical Care Management June 4th, 2020 Anthony Massaro, - - PowerPoint PPT Presentation

COVID-19 Critical Care Management June 4th, 2020

Anthony Massaro, MD

Medical Director, Medical ICU Medical Director, Special Pathogens ICU Co-Lead Critical Care Branch, Operations Section

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Disclosures

• No disclosures

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• Review management of Covid-19 Acute Respiratory Failure

– Goals – Outline treatments options – Highlight areas of controversy / new therapy

– Prone Ventilation (Pre-Intubation and Post Intubation) – High Flow Nasal Cannula – Non-Invasive Ventilation – Mechanical Ventilation Settings » Is Covid-19 ARDS different from ARDS?

• Review coagulation disorder

– VTE prophylaxis

Objectives

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• December 31, 2019

– China reports cluster of pneumonia cases in Wuhan, Hubei Province

• January 12, 2020

– Genetic sequence of COVID-19 shared

• January 30, 2020

– WHO declares Public Health Emergency of International Concern

• February 1, 2020

– UMass Boston student returning from Wuhan confirmed positive

• February 26-28, 2020

– Biogen – Two day leadership conference Boston Marriot Long Wharf Hotel

• March 2, 2020

– Female in 20’s traveled with group returning from Italy confirmed positive

• March 4, 2020

– Two Biogen executives returned from Italy tested positive

• March 11,2020

– WHO declares Pandemic

COVID -19 Boston

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COVID-19 +ve Inpatient Census BWH

Covid-19 Critical Illness Clinical Characteristics

Wuhan Wuhan Lombardy Seattle New York n=52 N=36 n=1591 n=24 N=257 Mechanical Ventilation (invasive and non-invasive) 71% 89% 99% 75% 80% Vasopressors 35% 36% 71% 66% Renal Replacement Therapy 17% 6% 31% Antibiotics 94% >64% 89% Mortality 61.5% 17% 26% 50% 39%

Yang et al. Lancet 2020; 8(5): 475-481 Wang et al. JAMA 2020; 323(11):1061-1069 Graselli et al. JAMA 2020: 323(16):1754-1581 Bhatraju PK et al. N Engl J Med 2020;382:2012-2022 Cummings et al. Lancet. https://doi.org/10.1016/ S0140-6736(20)31189-2

ICU Acute Respiratory Failure Therapies

Wuhan Wuhan Lombardy Seattle New York n=52 N=36 n=1591 n=24 N=257 High Flow Nasal Cannula (HFNC) 63.5% 11.1% 42% 5% CPAP or Non-Invasive Ventilation 56.0% 41.7% 11% 0% 1% Invasive Mechanical Ventilation 42.0% 47.2% 88% 75% 79% Prone Ventilation 11.5% 27% 28% 17% Neuromuscular blockade 39% 25% Inhaled Pulmonary Vasodilator 28% 11% Extracorporeal Membrane Oxygenation 11.5% 11.1% 1% 0% 3%

Yang et al. Lancet 2020; 8(5): 475-481 Wang et al. JAMA 2020; 323(11):1061-1069 Graselli et al. JAMA 2020: 323(16):1754-1581 Bhatraju PK et al. N Engl J Med 2020;382:2012-2022 Cummings et al. Lancet. https://doi.org/10.1016/ S0140-6736(20)31189-2

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• Goals:

– Maintain target SpO2 92-96% – Maintain stable work of breathing

• Goal respiratory rate < 24
• Target normal respiratory effort (no signs of accessory muscle use or obvious

increased respiratory work)

– Avoid excessive intrathoracic pressure » P-SILI

Management of Covid-19 Acute Respiratory Failure with Hypoxia

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• Nasal Cannula
• Venturi mask
• Non Rebreather Mask (NRB)
• Prone Ventilation (Awake – Self Proning)
• High Flow Nasal Cannula
• CPAP or Non-Invasive Ventilation
• Invasive Mechanical Ventilation

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• Initial report 1976
• Piehl and Brown
• Crit Care Med 1976;4;12-14
• Increase PaO2 = 47 torr
• Mechanism of improved
• xygenation?

Intensive Care Society – ICS Guidance for Prone Positioning

11 Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62(8): 1097-1110.

Detrimental Effects of Supine Ventilation

• Dorsal alveoli atelectasis
• Ventral alveoli over inflation
• V/Q mismatch
• Shunting
• Aspiration risk

12 Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62(8): 1097-1110.

Physiologic Benefits of Prone Ventilation

• Improved aeration of posterior lung
• Improved ventilation – perfusion

matching

• Reduced shunting
• Improved secretion clearance

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• Rare use in non-intubated patients

prior to Covid-19

– Scaravilli et al. Journal of Critical Care (2015) 30:6 – 15 patients / 5 years

Awake Prone Ventilation

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• Rare use in non-intubated patients prior to Covid-19

– Scaravilli et al. Journal of Critical Care (2015) 30:6 – 15 patients / 5 years

• Use in Covid-19

– Sun et al. Ann. Intensive Care (2020) 10:33 – Caputo et al. Academic Emergency Medicine (2020) 27:5

• 50 patients
• SpO2 80% (triage); 84% (supplemental O2 NRB or NC); 94% (prone)
• 13 intubated

Awake Prone Ventilation

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Awake prone Ventilation

Slessarev, M. et al. Can J Anesth/J Can Anesth(2020). https://doi.org/10.1007/s12630-020-01661-0

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• Nasal Cannula
• Venturi mask
• NRB
• Prone Ventilation (Awake – Self Proning)
• High Flow Nasal Cannula
• CPAP or Non-Invasive Ventilation
• Invasive Mechanical Ventilation

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• Pro

– Proven Efficacy in Acute Respiratory Failure with Hypoxia – Reduce need for ventilators

• Reduce utilization of sedation, neuromuscular blockade
• Con

– Particle dispersion (especially with cough)

• Mitigation interventions possible (mask, containment box)

– Utilization of potentially limited supplemental oxygen supplies

High Flow Nasal Cannula

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• Initiate after multidisciplinary

discussion

• Requires full Enhanced Respiratory

Precautions PPE

• Use mitigation interventions if

possible

High Flow Nasal Cannula

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• Nasal Cannula
• Venturi mask
• Prone Ventilation (Awake – Self Proning)
• High Flow Nasal Cannula
• CPAP or Non-Invasive Ventilation
• Invasive Mechanical Ventilation

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Ventilator Management - Is ARDS Different in Covid-19?

Gattinoni, L. et al.. COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. AJRCCM, 201(10), 1299-1300.

Ventilator Management in Covid-19 ARDS (CARDS)

16 Patients Compliance 50.2 + 1.6 ml/ cm H20 Shunt fraction 0.50+ 0.11

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Is Covid-19 ARDS Unique?

Gattinoni, L. et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes?. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-06033-2

Severe Hypoxemia with preserved Respiratory System Compliance ? Difference between early and late in disease?

Type L Type H Elastance Low High R to L shunt Low High Lung weight Low High Lung Recruitability Low High

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• 66 Patients
• 65% male
• Median Age = 58 yrs

Respiratory Mechanics In Covid-19

Ziehr et al. AJRCCM https://doi.org/10.1164/rccm.202004-1163LE

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• Low Tidal Volume Protective Ventilation
• Setting PEEP
• Prone Ventilation
• Neuromuscular Blockade
• Inhaled Pulmonary vasodilators
• ECMO

Ventilator Management in Covid-19 ARDS (CARDS)

24 Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62(8): 1097-1110.

Physiologic Benefits of Prone Ventilation

• Improved aeration of posterior lung
• Improved ventilation – perfusion

matching

• Reduced shunting
• Improved secretion clearance
• Lung Protective

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• PROSEVA Trial
• Multicenter, Randomized
• 466 patients
• Early application
• Prone positioning 16 hours
• Outcome: Proportion of deaths from any cause within 28

days after enrollment

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Kaplan–Meier Plot of the Probability of Survival from Randomization to Day 90.

Guérin C et al. N Engl J Med 2013;368:2159-2168

Guerin et al. N Engl J Med 368;23

30 Day Mortality Intervention = 16.0% Control = 32.8% 90 Day Mortality Intervention = 23.6% Control = 41.0%

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• Low Tidal Volume Protective Ventilation
• Setting PEEP
• Prone Ventilation
• Neuromuscular Blockade
• Inhaled Pulmonary vasodilators
• ECMO

Principles of Mechanical Ventilation in Covid-19

Covid-19 Coagulopathy

• Disseminated Intravascular Coagulation (DIC)
• ? Triggered by proinflammatory state
• Manifest as
• Microthrombus
• Venous thromboembolism
• Supported in autopsy studies
• Presence of DIC predicts mortality
• Tang et al. J Thromb Haemost. 2020;18:844–847.
• Increased incidence of VTE
• UP to 69% in ICU

VTE Prophylaxis Recommendations

• ICU Patients should get VTE prophylaxis
• Should dose be increased?
• At BWH ICU patients get increased dosing
• LMWH preferred
• No indication for both pharmacologic and mechanical prophylaxis
• What about patients with CVC, Aline, RRT clots?

Should Critically Ill Covid-19 patients receive therapeutic anticoagulation?

• 2,773 hospitalized Covid-19 patients
• Retrospective study / Observational
• Mount Sinai in New York
• 28% systemic anticoagulation

Mortality

• All - Anticoagulation 22.5 %, No Anticoagulation 22.8
• Mechanical Ventilation - Anticoagulation 29.1 %, No Anticoagulation 62.7%

Bleeding

• All - Anticoagulation 1.9 %, No Anticoagulation 3.0
• Paranipe et al. JACC 2020

Systemic Anticoagulation In Covid-19

https://doi.org/10.1016/j.jacc.2020.05.001.

Take Home

• Maintain SpO2 92-96%
• Intervene on excessive work of breathing
• Consider prone ventilation
• Consider HFNC
• Noninvasive ventilation if concomitant condition with proven benefit
• Key lessons regarding mechanical ventilation of ARDS apply
• Low tidal volume
• Prone Ventilation
• NMB
• More data needed on increase prophylaxis or routine anticoagulation

References

• BWH Covid Protocols
• www.covidprotocols.org
• NIH Covid Guidelines
• https://www.covid19treatmentguidelines.nih.gov/
• Grasselli, G., et al. (2020). "Baseline Characteristics and Outcomes of

1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy." JAMA 323(16): 1574-1581.

• Matthay, M. A., et al. (2020). "Treatment for severe acute respiratory

distress syndrome from COVID-19." Lancet Respir Med 8(5): 433-434.

• Connors, J. M. and J. H. Levy (2020). "COVID-19 and its implications

for thrombosis and anticoagulation." Blood.

Appendix

Prone Ventilation Studies

2001 2004 2006 2009 2014 Prone- Supine Prone- Supine II PROSEVA Gattinoni Guerin Mancebo Taccone Guerin Patients 304 791 142 342 474 Proning Dose >=6 >=8 20 >=20 >=16 PaO2:FiO2 <=300 <=300 <=200 100-200; <100 <150 Time Enrolled Not early Not early <48 hrs <72 hrs <36 hrs Mortality ICU 28 day ICU 28 day 28 day Prone 50.7% 32.4% 43% 31% 16% Control 48% 31.5% 58% 32.8% 32.8% RR 1.05 1.02 0.74 0.97 0.48 p=0.77 p=0.12 p=0.72 p<0.0001