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

Disclosures • No disclosures 2

Objectives • 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 3

COVID -19 Boston • 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 4

COVID-19 +ve Inpatient Census BWH 5

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 11.5% 11.1% 1% 0% 3% Oxygenation 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

Management of Covid-19 Acute Respiratory Failure with Hypoxia • 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 8

• 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 9

• Initial report 1976 • Piehl and Brown • Crit Care Med 1976;4;12-14 • Increase PaO2 = 47 torr • Mechanism of improved oxygenation? Intensive Care Society – ICS Guidance for Prone Positioning 10

Detrimental Effects of Supine Ventilation • Dorsal alveoli atelectasis • Ventral alveoli over inflation • V/Q mismatch • Shunting • Aspiration risk Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62 (8): 1097-1110. 11

Physiologic Benefits of Prone Ventilation • Improved aeration of posterior lung • Improved ventilation – perfusion matching • Reduced shunting • Improved secretion clearance Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62 (8): 1097-1110. 12

Awake Prone Ventilation • Rare use in non-intubated patients prior to Covid-19 – Scaravilli et al. Journal of Critical Care (2015) 30:6 – 15 patients / 5 years 13

Awake Prone Ventilation • 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 • SpO 2 80% (triage); 84% (supplemental O 2 NRB or NC); 94% (prone) • 13 intubated 14

Awake prone Ventilation Slessarev, M. et al. Can J Anesth/J Can Anesth (2020). https://doi.org/10.1007/s12630-020-01661-0 15

• Nasal Cannula • Venturi mask • NRB • Prone Ventilation (Awake – Self Proning) • High Flow Nasal Cannula • CPAP or Non-Invasive Ventilation • Invasive Mechanical Ventilation 16

High Flow Nasal Cannula • 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 17

High Flow Nasal Cannula • Initiate after multidisciplinary discussion • Requires full Enhanced Respiratory Precautions PPE • Use mitigation interventions if possible 18

• Nasal Cannula • Venturi mask • Prone Ventilation (Awake – Self Proning) • High Flow Nasal Cannula • CPAP or Non-Invasive Ventilation • Invasive Mechanical Ventilation 19

Ventilator Management - Is ARDS Different in Covid-19? Ventilator Management in Covid-19 ARDS (CARDS) 16 Patients Compliance 50.2 + 1.6 ml/ cm H20 Shunt fraction 0.50+ 0.11 Gattinoni, L. et al.. COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. AJRCCM, 201 (10), 1299-1300. 20

Is Covid-19 ARDS Unique? 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 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 21

Respiratory Mechanics In Covid-19 • 66 Patients • 65% male • Median Age = 58 yrs Ziehr et al. AJRCCM https://doi.org/10.1164/rccm.202004-1163LE 22

Ventilator Management in Covid-19 ARDS (CARDS) • Low Tidal Volume Protective Ventilation • Setting PEEP • Prone Ventilation • Neuromuscular Blockade • Inhaled Pulmonary vasodilators • ECMO 23

Physiologic Benefits of Prone Ventilation • Improved aeration of posterior lung • Improved ventilation – perfusion matching • Reduced shunting • Improved secretion clearance • Lung Protective Johnson, N. J., et al. (2017). "Gas Exchange in the Prone Posture." Respir Care 62 (8): 1097-1110. 24

• PROSEVA Trial • Multicenter, Randomized • 466 patients • Early application • Prone positioning 16 hours • Outcome: Proportion of deaths from any cause within 28 days after enrollment 25

Kaplan – Meier Plot of the Probability of Survival from Randomization to Day 90. 30 Day Mortality Intervention = 16.0% Control = 32.8% 90 Day Mortality Intervention = 23.6% Control = 41.0% Guérin C et al. N Engl J Med 2013;368:2159-2168 Guerin et al. N Engl J Med 368;23 26

Principles of Mechanical Ventilation in Covid-19 • Low Tidal Volume Protective Ventilation • Setting PEEP • Prone Ventilation • Neuromuscular Blockade • Inhaled Pulmonary vasodilators • ECMO 27

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