Not Your Typical ARDS: the high-stakes debate about ICU Covid intubation

This video is by a physician involved in what I discuss below and is a great TL;DR.

I decided to do some digging when I came across this note from Luciano Gattinoni (as a critical care physician on Twittter says “THE world expert on ARDS”) and colleagues in the American Journal of Respiratory and Critical Care Medicine. The letter notes some unusual features in Gattinoni’s first 16 patients (small number, no RCT disclaimers).

The gist is summarized as

The patients with Covid-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing (confirmed by colleagues in other hospitals), is the dissociation between their relatively well preserved lung mechanics and the severity of hypoxemia

Why does this matter? Well one side of a debate raging on medical Twitter thinks that our kneejerk approach to treating ARDS is causing harm for at least some patients.

The normal reaction to very low oxygen saturation is to intubate and put people on mechanical ventilation. Many physicians on Twitter are arguing that instead of intubating reflexively, doctors should consider the intermediate step of using CPAP machines and nasal canula (non-invasive ventilation) for more severely low oxygen saturation than they’d normally be comfortable with.

Physicians on this side of the debate suggest making the intubation decision based on observing the patient–whether they’re alert & responsive–rather observing their oxygen saturation.

A good piece of audio on this was a recent discussion on EMCrit called Stop Kneejerk Intubation

The other side brings additional nuance to the debate

At the end of the day, this debate will need a lot more evidence to have any chance of resolving, but doing so is crucial.

UPDATE 4/6/20 American Academy of Emergency Medicine hosts a podcast about ARDSnet and early intubation

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