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.
We are at a critical juncture where there are two competing and contradictory opinions about the management of #COVID19 respiratory failure. We think the ARDSnet protocol, high PEEP, is a dead-end and will cost thousands of extra lives. @cameronks https://t.co/q6l38fxxMo— Mert Erogul (@erogul1) April 2, 2020
At what point are we allowed to say that this HIGH compliance disease that does not lead to respiratory fatigue just straight up IS NOT ARDS. I’m trying to figure out what about it is ARDS other than the crappy X-ray and hypoxemia.— Cameron Kyle-Sidell, MD (@cameronks) April 3, 2020
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.
I agree with @cameronks we need to stop intubating patients early in #COVID19 disease course...these patients need O2 not pressure...putting them on ventilators will trash their lungs...this is not ARDS...these patients act more like HAPE#COVID19FOAM pic.twitter.com/mYM558G2YS— Salim R. Rezaie, MD (@srrezaie) April 1, 2020
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.
Browsing on phone w that O2 sat. #COVID19 tips from NYC. Anecdotal for now.— Eric Lee MD (@EricLeeMD) March 31, 2020
1. Proning patients helps O2 sats. Have them lie on belly.
2. Don't intubate for low O2 sats alone. Look at mental and resp status. Hi-Flo NC helps. https://t.co/MKoFq1c2Hs#FOAMed #medtwitter pic.twitter.com/v9UgtIVqCx
Awake & talking on HFNC no dyspnea. We need to accept lower saturations than what we are used to! PaO2 also low on ABG. Treat the patient not the number! Treat a new disease w/old treatments & you'll get old results!@cameronks @srrezaie @precordialthump @ThinkingCC #COVIDfoam pic.twitter.com/RbNpaGZ95e— Mark Ramzy DO, EMT-P (@MRamzyDO) April 2, 2020
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
Crucial point.— Roberto Cosentini (@rob_cosentini) April 2, 2020
30% of our #COVID19 pts are ARDS (SpO2 <90% w/ reservoir 15 L and need PEEP
The trouble with Helmet CPAP/NIV is high negative Pleural pressure that damages the lung (patient-SILI)
ETI advantage is muscles rest
CPAP may cure a small group of pts and buy time to ICU https://t.co/Qs8R42XfVE
Absence of tachycardia/distress/fatigue is not = safe hypoxemia. Your post includes no info about organ tissue sats to support this statement. That requires catheterization to measure O2 extraction for individual organs. Generalizations in all caps/N=1 doesn’t help.— Martin Sundström (@decafmartin) March 30, 2020
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
In this episode, we are featuring a podcast from REBEL EM Cast hosted by Dr. Salim Rezaie @srrezaie discussing trying not to intubate early & why ARDSnet may be the wrong ventilator paradigm during COVID-19. View additional resources at: https://t.co/1hkt3UUzXC pic.twitter.com/niaKKthJKn— AAEM (@aaeminfo) April 6, 2020