Episode 23: COVID-19 pneumonia with Nicole King

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Best practices in care of the critically ill patient with COVID-19 pneumonia are not known at this time. However, practical lessons from the ground are filtering in from those who have seen many of these patients, and Dr. Nicole King—critical care anesthesiologist, ECMO-ologist at the University of Cincinnati, and alumnus of the New York City COVID surge—is here to walk us through her experiences.

Takeaway lessons

1. Do your swabs, cultures, and antigens to check for other viral and atypical pneumonias; other diseases still exist.
2. Check a D-dimer to stratify hypercoagulability.
3. Worsening tachypnea, distress, and ventilatory (not hypoxic) failure are a marker to upgrade care and/or intubate a borderline COVID patient.
4. Treat initially with steroids per the RECOVERY trial (dexamethasone 6 mg daily for 10 days); then, if needing ICU or especially if needing intubation, consider the DEXA-ARDS protocol (20 mg daily for 5 days, then 10 mg daily for another 5 days). You may consider remdesevir or convalescent plasma at this point in the science, but don’t expect too much effect.
5. Very prolonged courses on non-invasive positive pressure ventilation (CPAP/BiPAP) may be more acceptable here than in other diseases; although not very appealing it may be preferable to intubation. Try cycling on and off to improve tolerability. Consider an NG tube for nutrition.
6. However, beware of profoundly large tidal volumes in spontaneously breathing patients due to their remarkable air hunger, which may predispose to lung injury—spontaneous pneumothorax can occur even in these non-invasive patients.
7. When air hunger is profound, you may need to decide whether to sedate them to control tidal volumes, or allow (potentially harmful) large volumes, or try to limit them with the vent with the possible result of a dyssynchronous and air hungry patient.
8. It’s not clear whether intubation worsens outcomes, but it’s clear that the patients who require intubation seem to do very poorly; part of the reason may be selection for high-risk patients as we try to avoid intubating when possible, but part may be iatrogenesis from things like sedation and paralysis.
9. PEEP is not very high-yield on many of these patients—either they need little recruitment (good compliance) or their compliance is so poor they are minimally recruitable—but since they are frequently so borderline, they still often end up on high PEEPs because they need whatever little margin of recruitment it does provide.
10. APRV makes sense and may have a role, but you will generally need to avoid paralysis and lighten sedation, as CO2 can become very hard to manage without significant spontaneous breathing.
11. Prone early, when the lungs are still recruitable and salvageable. It’s unclear whether it’s beneficial for lung protection even when the benefit on oxygenation is not impressive. It can be logistically challenging due to obesity and hemodynamic instability.
12. If considering ECMO, do it early. A prolonged course (intubated >10–14 days or on high vent settings for >7 days) is a contraindication, as permanent lung injury has already set in and recovery is less likely. To achieve this, aggressively manage early with usual methods, then if they seem to be refractory, consider ECMO as soon as the trajectory is clear—don’t give them a “waiting period” of days/weeks of vent failure first.
13. VV ECMO is usually adequate, particularly if you cannulate early enough that cardiovascular collapse has not set in, and may limit the iatrogenic harms. Whether VA ECMO may have a role for those with PE and RV strain is unclear.
14. Early tracheostomy is reasonable, but it’s not a panacea—most patients still end up needing significant vent support, sedation, etc.
15. 20 days after their initial symptom onset, patients are likely no longer infectious and isolation precautions can be withdrawn, regardless of testing.
16. During and perhaps for a prolonged period after their peak illness, some of these patients will have a persistently elevated respiratory drive—tachypnea, high minute ventilations and work of breathing—that may not portend anything acutely untoward, or at least may not be preventable.
17. When patients start looking worse, look at the right heart, which will often be strained from high PEEP and/or the presence of PEs. Treat the latter, and consider inhaled pulmonary vasodilators.