Experience in getting COVID pts off vent

[Nephro critical care]

I don’t know if other people have had a similar experience but at my 3 hospitals we haven’t had much success in getting COVID pts extubated in the second surge. Some got trached ; some maybe have gone to LTACH but nobody got extubated and did well. Is it because we keep people on vapotherm / Bipap much more than we would keep the regular ARDS pt and they develop barotrauma ?

I remember in the first surge I had pts who were on 12- 15 L and I didnt sit on them for days. I intubated and did standard ARDS management with prone/ paralysis as needed and few days later they came off vent and actually discharged on RA. But I don’t see that in the 2nd surge. And I see a lot more PTX and pneumomediastinum now.

What is the prognosis for someone > 60 yrs who spent 3-4 days on 90-100 % vapotherm or Bipap and then got bad enough to need intubation ?

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[CCM-MD]

We have had a similar experience. Very few extubations recently. Those who survive end up trach’d. Have seen several patients with extensive spontaneous subcutaneous emphysema - no one has done well. We’ve been trying to avoid intubation with NIV for as long as possible, I have similar concerns about possible lung injury due to this.

 

[Nephro critical care]

I have read some talk in the mainstream media about rationing care for some COVID pts. I have had moral issues with that and I am not comfortable with rationing care.
But I would be comfortable in telling a pts on 3rd line chemotherapy for metastatic cancer that it does not make sense to do mechanical ventilation/CPR. If I knew for sure that there was a type of COVID pt who had a similar prognosis then I would have less moral distress telling that to family.

 

[chocomorsel]

Bad. They are all dying. Even my trached ones.
But I have never had much success in my travel journeys. Always experienced greater >75% mortality once tubed so have never experienced this 40% some of y’all speak of. Only read about it. Even in NY in the spring they were dying and people weren’t sitting around forever with vapotherm and BiPap.
Maybe it’s the strain? Maybe it’s evolved to be more deadlier? Who knows.
I take care of a lot of Hispanics and mortality is high, high, high.

 

[grt398]

I'm not sure my hospital has seen much difference lately and we still keep them on HFNC/BiPAP as long as tolerated. Most who end up vented will die. I haven't looked into our data but anecdotally I feel like it's age that's most predictive, i.e. more of our people in their 40s/50s with transplants who were actively immunosuppressed at baseline seem to get off the vent than the 60+ age group with the usual HTN/COPD/T2DM/CAD etc. But I realize I probably have some element of survivorship bias in my memory.

 

[Nephro critical care]

One characteristic I have noted in immunosuppressed patients is that they don’t seem to be able to clear the virus. They will get better and be on 1-2 L and even get discharged but will come back with a recurrence in a week with positive PCRs.
If someone is on Rituximab and mycophenolate they aren’t going to be able to develop a meaningful antibody response.

 

[turkeyjerky]

Are you saying that you suspect P-SILI? Or are you saying that, once invasive mechanical ventilation is required, the required pressures end up being so high they develop barotrauma?

Maybe it's a function of being able to keep a portion of the ones who previously were dying alive, but their lung injury is just too severe to liberate...

Anyone using high dose methylpred like Marik seems to be all about?

 

[chocomorsel]

I'm not sure my hospital has seen much difference lately and we still keep them on HFNC/BiPAP as long as tolerated. Most who end up vented will die. I haven't looked into our data but anecdotally I feel like it's age that's most predictive, i.e. more of our people in their 40s/50s with transplants who were actively immunosuppressed at baseline seem to get off the vent than the 60+ age group with the usual HTN/COPD/T2DM/CAD etc. But I realize I probably have some element of survivorship bias in my memory.

Any kidney transplants survive after intubation?

 

[CCM-MD]

Any kidney transplants survive after intubation?

I’ve had 2 patients survive the acute illness... their transplanted kidneys may not have, time will answer that question. Both ended up trach’d and on CRRT and subsequently HD. Second one going to LTAC this week. Still making some urine so maybe there is some hope.

 

[chocomorsel]

I’ve had 2 patients survive the acute illness... their transplanted kidneys may not have, time will answer that question. Both ended up trach’d and on CRRT and subsequently HD. Second one going to LTAC this week. Still making some urine so maybe there is some hope.

I have seen some bad management on the part of the nephrologist and the pulmonary docs all in the effort to “save the transplanted kidney.” And in the process the patients die with their lovely tansplanted kidneys intact simply because they refused to even diurese. Patient looked like the Michelin man when I met him and he promptly died that day of metabolic and respiratory acidosis. The second one in the hospital. Makes no damn sense. Apparently as of six weeks ago “no transplant kidney patient had survived the Covid once intubated according to that pulmonologist.
Guess you are making history.

Left that place quickly for multiple other reasons.

 

[CCM-MD]

I have seen some bad management on the part of the nephrologist and the pulmonary docs all in the effort to “save the transplanted kidney.” And in the process the patients die with their lovely tansplanted kidneys intact simply because they refused to even diurese. Patient looked like the Michelin man when I met him and he promptly died that day of metabolic and respiratory acidosis. The second one in the hospital. Makes no damn sense. Apparently as of six weeks ago “no transplant kidney patient had survived the Covid once intubated according to that pulmonologist.
Guess you are making history.

Left that place quickly for multiple other reasons.

I didn’t do anything special. Both had extensive complicated hospital courses. Our numbers are the worst they have ever been, so our outcomes are probably about to get even worse than they have been.

 

[chocomorsel]

I didn’t do anything special. Both had extensive complicated hospital courses. Our numbers are the worst they have ever been, so our outcomes are probably about to get even worse than they have been.

Diuresing a balloon with rising renal function tests and decreasing UOP seems like common sense to me.

 

[Nephro critical care]

Kidney transplants at least have a choice. Life versus life on dialysis. I had a pt post heart transplant with antibody mediated rejection who got the full court press with plasmapheresis, IVIG and rituximab get COVID a week later and end up with full blown ARDS. I was taking care of him and was thinking how he was going to clear his viremia.

 

[Nephro critical care]

Are you saying that you suspect P-SILI? Or are you saying that, once invasive mechanical ventilation is required, the required pressures end up being so high they develop barotrauma?

Maybe it's a function of being able to keep a portion of the ones who previously were dying alive, but their lung injury is just too severe to liberate...

Anyone using high dose methylpred like Marik seems to be all about?

I am extremely reluctant to keep any COVID pts solely on Bipap support for longer than a few hours. Vapotherm maybe.
And I like to keep pts paralyzed for 24 hours post intubation as the most P-SILI occurs in the immediate post intubation period. Patients seem to be have more difficulty with synchrony in that time period.

 

[CCM-MD]

I am extremely reluctant to keep any COVID pts solely on Bipap support for longer than a few hours. Vapotherm maybe.
And I like to keep pts paralyzed for 24 hours post intubation as the most P-SILI occurs in the immediate post intubation period. Patients seem to be have more difficulty with synchrony in that time period.

We’ve been doing Optiflow/NIV for as long as we can to avoid intubation. Majority that sick do end up intubated but there are some that we avoid intubating.

 

[grt398]

Any kidney transplants survive after intubation?

Two so far. The most recent was on the vent for almost 3 weeks, managed to get extubated and transferred to the COVID floor with 12L NC. Didn't come back to the ICU. I should have followed up on final dispo but didn't. My institution has been taking the approach that the kidney can be sacrificed if the lungs become a higher priority, so we do diurese as needed.

 

[grt398]

We’ve been doing Optiflow/NIV for as long as we can to avoid intubation. Majority that sick do end up intubated but there are some that we avoid intubating.

We're also doing this

 

[WheezyBaby]

I've been out of the adult ICU for a bit. Are these high compliance severely hypoxemic patients just typically getting treated with high FiO2? Will they just sit on >70% fio2 high flow for days if work of breathing is reasonable? Or are people escalating to NIPPV / tubing for refractory hypoxemia alone (assuming correctable with fio2 <1)? Does the hypoxemia tend to be PEEP responsive? I'm med peds and have been caring for kids primarily recently, but when I was in the ICU with the adults we had almost exclusively the low compliance ARDS-y cohort, so never got much experience with the "happy hypoxemics"

 

[chocomorsel]

I've been out of the adult ICU for a bit. Are these high compliance severely hypoxemic patients just typically getting treated with high FiO2? Will they just sit on >70% fio2 high flow for days if work of breathing is reasonable? Or are people escalating to NIPPV / tubing for refractory hypoxemia alone (assuming correctable with fio2 <1)? Does the hypoxemia tend to be PEEP responsive? I'm med peds and have been caring for kids primarily recently, but when I was in the ICU with the adults we had almost exclusively the low compliance ARDS-y cohort, so never got much experience with the "happy hypoxemics"

More so the low compliance type but occasionally you get a bone thrown in with the high compliance type.
Yes, they sit on HFNC and BiPap for days and many do well with just that combo. As long as their kidneys stay healthy.

 

[deleted547339]

I have seen some bad management on the part of the nephrologist and the pulmonary docs all in the effort to “save the transplanted kidney.” And in the process the patients die with their lovely tansplanted kidneys intact simply because they refused to even diurese. Patient looked like the Michelin man when I met him and he promptly died that day of metabolic and respiratory acidosis. The second one in the hospital. Makes no damn sense. Apparently as of six weeks ago “no transplant kidney patient had survived the Covid once intubated according to that pulmonologist.
Guess you are making history.

Left that place quickly for multiple other reasons.

Show me on the doll where the pulmonologist touched you.

 

[deleted547339]

I have read some talk in the mainstream media about rationing care for some COVID pts. I have had moral issues with that and I am not comfortable with rationing care.
But I would be comfortable in telling a pts on 3rd line chemotherapy for metastatic cancer that it does not make sense to do mechanical ventilation/CPR. If I knew for sure that there was a type of COVID pt who had a similar prognosis then I would have less moral distress telling that to family.

You’d better get comfortable with it. Rationing care isn’t something anyone wants to do, but it may be something you have to do. If you aren’t willing to make the hard decisions, who will? Administrators? Your colleagues?

 

[chocomorsel]

Show me on the doll where the pulmonologist touched you.

WTF? Are you high?

 

[deleted547339]

WTF? Are you high?

No, but that’s like the third desparaging thing you’ve said about medical intensivists in the past couple days

 

[chocomorsel]

No, but that’s like the third desparaging thing you’ve said about medical intensivists in the past couple days

Nope. I said two things about pulmonologists disappearing after rounds and about a specific pulmonologist and some nephrologists focusing on saving a transplanted kidney instead of the whole patient. And then proceeded to complement another medical (I think) intensivist on how he handled a renal transplant patient.
Like I said, have seen it, experienced it, heard it from multiple sources. It is what it is. You call it disparaging, I call it reality. Quit trying to pick a fight.

No one touches me inappropriately or they will be slapped. Learned that a long time ago.

 

[jdh71]

So the argument from some seems to be there is less barotrauma from the vent versus the NIPPV? I’m not convinced HFNC gives any significant barotrauma.

The ventilator seems to be the beginning of the problems not the end of them. If one needs the vent they are going to die. I’ve gotten no recent male ventilated patients off the vent. That is likely because we are waiting to intubate until absolutely necessary and at that point the vent isn’t really the problem, it’s the lungs. They don’t liberate because they never were going to. It’s like the BMT folks telling you the high mortality rates when those patients get mechanically ventilated like it’s the vent’s fault. These people are just that sick.

I would agree with @chocomorsel that in general Latino men are going to die if they reach the point of mechanical ventilation. This is also my biggest patient population in the ICU on vents. We do not have a large black population where I work and I’ve seen one black Hispanic and he didn’t make it.

I’ve gotten a few women off the vent this time around. One was even a BIG gal with the underlying hypoventilatory issues. She was Caucasian. Mid 40s.

It’s all pretty unsatisfactory work. Many of those who survived to discharge to LTAC were not only trached and still on my a vent but also had significant strokes and clear neurological deficits.

 

[chocomorsel]

I am extremely reluctant to keep any COVID pts solely on Bipap support for longer than a few hours. Vapotherm maybe.
And I like to keep pts paralyzed for 24 hours post intubation as the most P-SILI occurs in the immediate post intubation period. Patients seem to be have more difficulty with synchrony in that time period.

So how long do you keep them on BiPap before intubating?
And what are the BiPap settings versus the Ventilator settings?
And what percentage of patients survive once you intubate them?
In my experience, the ones who stay off the vent are the ones who survive. I keep them on BiPap as long as they are mentating and comfortable. Diurese PRN because nurses are scared to give them water and I want no kidney failure and add Precedex to the rescue. No time limit.

Problem is, on my week off many end up intubated. Maybe they got worse, maybe the docs are scared. I have heard both sides.

Keep them off the vent until they peeter out.

 

[chocomorsel]

So the argument from some seems to be there is less barotrauma from the vent versus the NIPPV? I’m not convinced HFNC gives any significant barotrauma.

The ventilator seems to be the beginning of the problems not the end of them. If one needs the vent they are going to die. I’ve gotten no recent male ventilated patients off the vent. That is likely because we are waiting to intubate until absolutely necessary and at that point the vent isn’t really the problem, it’s the lungs. They don’t liberate because they never were going to. It’s like the BMT folks telling you the high mortality rates when those patients get mechanically ventilated like it’s the vent’s fault. These people are just that sick.

I would agree with @chocomorsel that in general Latino men are going to die if they reach the point of mechanical ventilation. This is also my biggest patient population in the ICU on vents. We do not have a large black population where I work and I’ve seen one black Hispanic and he didn’t make it.

I’ve gotten a few women off the vent this time around. One was even a BIG gal with the underlying hypoventilatory issues. She was Caucasian. Mid 40s.

It’s all pretty unsatisfactory work. Many of those who survived to discharge to LTAC were not only trached and still on my a vent but also had significant strokes and clear neurological deficits.

I don’t have the research but couldn’t agree more. I can’t imagine HFNC could cause much lung damage.

 

[CCM-MD]

So how long do you keep them on BiPap before intubating?
And what are the BiPap settings versus the Ventilator settings?
And what percentage of patients survive once you intubate them?
In my experience, the ones who stay off the vent are the ones who survive. I keep them on BiPap as long as they are mentating and comfortable. Diurese PRN because nurses are scared to give them water and I want no kidney failure and add Precedex to the rescue. No time limit.

Problem is, on my week off many end up intubated. Maybe they got worse, maybe the docs are scared. I have heard both sides.

Keep them off the vent until they peeter out.

This is almost exactly how my group is managing.

 

[Radetzky]

So my reading of the ARDS literature is that, unless you make a dramatic improvement within the first few hours, non invasive ventilation worsens your mortality significantly. How does that square with what you guys are describing here of keeping people on NIV as long as possible?

 

[bigtuna]

Totally anecdotal but we are having somewhat better results that what many of you are describing. We are successfully extubating around 15%. Also very high percentage hispanic patients.

We generally do not use bipap and intubate when they fail HFNC.

We are an ECMO center and having terrible results with the ECMO patients. Our ECMO director is considering not doing any more VV-ECMO on COVID patients.

 

[WheezyBaby]

Totally anecdotal but we are having somewhat better results that what many of you are describing. We are successfully extubating around 15%. Also very high percentage hispanic patients.

We generally do not use bipap and intubate when they fail HFNC.

We are an ECMO center and having terrible results with the ECMO patients. Our ECMO director is considering not doing any more VV-ECMO on COVID patients.

Bleeding thrombosis or both? Or other?

 

[bigtuna]

Bleeding thrombosis or both? Or other?

A couple unexpected ich’s in young people on low level anticoagulation and a lot of sepsis/bacteremia’s that we rarely see in our non covid ecmo’s.

 

[deleted547339]

We’re doing very little NIPPV. A lot of HFNC, inhaled epo and awake proning. We’re proning almost everyone on the vent. Don’t have a big Hispanic population here, but a lot of black people. I’ve gotten kidney xplant folks off the vent, but the first that comes to mind was still on HFNC a month later. Had a cirrhotic rally.

 

[chocomorsel]

Totally anecdotal but we are having somewhat better results that what many of you are describing. We are successfully extubating around 15%. Also very high percentage hispanic patients.

We generally do not use bipap and intubate when they fail HFNC.

We are an ECMO center and having terrible results with the ECMO patients. Our ECMO director is considering not doing any more VV-ECMO on COVID patients.

Why aren’t you using BiPap? Mortality with this illness is high and worse with intubation. We are all just experimental with this disease to be honest.
What do you have to lose and why are you against BiPap? Inexperience? Because this is how we’ve always done it?
What do you have to lose?

 

[deleted547339]

Why aren’t you using BiPap? Mortality with this illness is high and worse with intubation. We are all just experimental with this disease to be honest.
What do you have to lose and why are you against BiPap? Inexperience? Because this is how we’ve always done it?
What do you have to lose?

We’re doing reasonably well with HFNC and epo. Seems like these folks done need help with ventilation and will need it for days, not hours - and none of us like leaving someone with the mask on for 3+ days.

 

[chocomorsel]

So my reading of the ARDS literature is that, unless you make a dramatic improvement within the first few hours, non invasive ventilation worsens your mortality significantly. How does that square with what you guys are describing here of keeping people on NIV as long as possible?

They tend to live when they don't get intubated. I am going to keep saying that. I am unsure of why people are against Bipap. How much more harmful is it really than Invasive Ventilation. It's all positive pressure and unless you have them on a rate and they are asynchronous, how is it any more harmful than a ventilator?

No I don't go by the research on this one as it's too new to have anything meaningful yet. I go by other people's anecdotal experience as it's the best we have as of right now. In my travels, I have seen what works and doesn't seem to work. What works is not intubating and diuresing, preventing AKI, proning, and Precedex. Intubation helps few of these people so it's best to hold off as long as possible. It's not about the numbers, it's about the patient. It's not about the doctors and nurses being uncomfortable, it's about the patients surviving. Our mindset needs to change.

In the beginning when it was uncool to use steroids, we were using them based on what one of the big name Italian docs was saying. I don't believe any of the medications besides maybe steroids work and all we are doing is buying these people time, supporting them until their bodies either decide to heal or give out.

And please give them fluid when they get pre renal.

 

[chocomorsel]

We’re doing reasonably well with HFNC and epo. Seems like these folks done need help with ventilation and will need it for days, not hours - and none of us like leaving someone with the mask on for 3+ days.

Ok. But why is that? Why don't you like it? Because it makes you uncomfortable?

 

[CCM-MD]

Probably subjecting more patients to invasive mechanical ventilation than necessary if you aren’t using NIPPV.

 

[deleted547339]

Ok. But why is that? Why don't you like it? Because it makes you uncomfortable?

Pressure ulcers. Inability to talk and eat. I just don’t think NIPPV is a functional solution for something that lasts more than a day or two.

Also, I really haven’t seen many, if any, do well enough to mitigate intubation with NIPPV that didn’t do well on HFNC, proning and epo.

 

[deleted547339]

So my reading of the ARDS literature is that, unless you make a dramatic improvement within the first few hours, non invasive ventilation worsens your mortality significantly. How does that square with what you guys are describing here of keeping people on NIV as long as possible?

Thats not a great reason to not use it. That is almost certainly simply an issue of not intubating when it’s appropriate. Same as delayed NIPPV being associated with mortality as a rescue for failed extubation. Doubt NIV hurts, it’s probably a bad doctor that hurts.

 

[chocomorsel]

Pressure ulcers. Inability to talk and eat. I just don’t think NIPPV is a functional solution for something that lasts more than a day or two.

Also, I really haven’t seen many, if any, do well enough to mitigate intubation with NIPPV that didn’t do well on HFNC, proning and epo.

You flip them between the HFNC and Bipap so that they can eat and get a break. They don't need to talk much. Need to save their energy for survival and PT. Give them something for anxiety and/or have nurses if available give them TLC.
I have seen many sit on bipap for >7 days eventually make their way down to just HFNC. I know some are longer because sometimes I come back and they are off my service and didn't die.
We aren't using epo so maybe that is something I should try.

How do you know that many don't do well on NIPPV if you aren't trying it out more than a couple of days? You won't see it unless you try it. This statement doesn't compute. Mindset needs to change.

 

[deleted547339]

You flip them between the HFNC and Bipap so that they can eat and get a break. They don't need to talk. Need to save their energy for survival and PT. Give them something for anxiety and/or have nurses if available give them TLC.
I have seen many sit on bipap for days and days and eventually make their way down to just HFNC.
We aren't using epo so maybe that is something I should try.

How do you know that you haven't seen many do well on NIPPV if you aren't trying it out more than a couple of days? You won't see it unless you try it. This statement doesn't compute. Mindset needs to change.

We exclusively used NIPPV earlier in the pandemic. We started seeing better results with the combination of high flow and epo. I think someone is working on a paper.

 

[chocomorsel]

We exclusively used NIPPV earlier in the pandemic. We started seeing better results with the combination of high flow and epo. I think someone is working on a paper.

Well now you are teaching me something new as well. I know we have iNO. Gonna ask the RTs to see if they can hook it up with HFNC/Bipap for the non intubated ones who aren't progressing well. Don't think they can use it with most of the Bipap machines though because we are always swapping them out when someone needs iNO for the larger vents. I don't know if they have Epo but will ask. I hear iNO is ridiculously expensive.
Always learning something new.

 

[CCM-MD]

I would be interested in adding epo to the non invasive toolkit. We don’t have it at my institution despite my asking for a while. I used it a lot in training for intubated patients, usually severe ARDS patients that weren’t ECMO candidates. I have never used it with NIPPV or HFNC.

 

[deleted547339]

Well now you are teaching me something new as well. I know we have iNO. Gonna ask the RTs to see if they can hook it up with HFNC/Bipap for the non intubated ones who aren't progressing well. Don't think they can use it with most of the Bipap machines though because we are always swapping them out when someone needs iNO for the larger vents. I don't know if they have Epo but will ask. I hear iNO is ridiculously expensive.
Always learning something new.

My understanding is that we can’t run it on our NIV. Yea. iNO is insanely expensive, we don’t use it (you have to give up your first born to get it). I’ve seen people with ABGs on arrival with PaO2 as low as the 30s get by with this method.

Our current intubated mortality is a little over 50%. Were super aggressive about proning. Like super aggressive.

 

[Radetzky]

Thats not a great reason to not use it. That is almost certainly simply an issue of not intubating when it’s appropriate. Same as delayed NIPPV being associated with mortality as a rescue for failed extubation. Doubt NIV hurts, it’s probably a bad doctor that hurts.

Yes I know. But my experience of NIV in other diffuse pneumonitis has been resoundingingly negative (in the cohort that needs it for greater than 24 hours).

My country has gotten away with few covid cases though so I’m trying to understand what your guys experience is with it that I don’t have.

 

[deleted547339]

Yes I know. But my experience of NIV in other diffuse pneumonitis has been resoundingingly negative (in the cohort that needs it for greater than 24 hours).

My country has gotten away with few covid cases though so I’m trying to understand what your guys experience is with it that I don’t have.

Ugh. I had more than a dozen on the vent just on my service last week.

 

[chocomorsel]

My understanding is that we can’t run it on our NIV. Yea. iNO is insanely expensive, we don’t use it (you have to give up your first born to get it). I’ve seen people with ABGs on arrival with PaO2 as low as the 30s get by with this method.

Our current intubated mortality is a little over 50%. Were super aggressive about proning. Like super aggressive.

So Epo is cheaper then?
Please elaborate about being "super aggressive" with proning. On what vent settings, for how long/per day? If they don't show benefit do you keep trying? I do it when they require high vent settings not on moderate to low, although I see other teams doing it.

 

[chocomorsel]

Yes I know. But my experience of NIV in other diffuse pneumonitis has been resoundingingly negative (in the cohort that needs it for greater than 24 hours).

My country has gotten away with few covid cases though so I’m trying to understand what your guys experience is with it that I don’t have.

If only I could tolerate the cold and gloom I would be there in a heart beat!! More power to you. For some reason I am thinking Canada.

 

[CCM-MD]

If only I could tolerate the cold and gloom I would be there in a heart beat!! More power to you. For some reason I am thinking Canada.

I'm Canadian. Its a pain to go back. I just got my FRCPC in IM this year - much more painful exam than the ABIM. Still have to take CCM. Don't know what its like for anesthesia. CCM jobs in the major metropolitan areas are also scarce. And the creatinine, glucose, and some other labs are in totally different units, which is a pain.

We usually prone if PF <150 with FiO2 needs >60%. 16-18 hour sessions in prone position. Curious what others are doing.