Posted on 04/06/2020 2:05:51 AM PDT by wastoute
Well, it’s, what is this? Day 6 of Q&A? We have pretty well covered “masks”, every one is an expert on epidemiology. Are there any questions left?
I have one.
What do you think about the doctor (Cameron Kyle-Sidell) who has concerns about the way patients are being ventilated?
Sorry. Quit doing YouTube’s years ago. What is his recommendation? MomMD posted something about how they do it now days. My experience in ICUs was in the 80s.
“Sorry. Quit doing YouTube’s years ago. What is his recommendation? MomMD posted something about how they do it now days. My experience in ICUs was in the 80s.”
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Ping
What I recall is, in my day, “Stents” weren’t an option. If your coronary needed “help” you sacrificed at least one veiniest in your leg and got you sternum sawed in half. So probably over 50% of the people who passed through my 15 bed ICU were only on the vent for a day or so. They “bounced back” pretty fast for the most part so the 4 or 5 hearts a day we did were the largest single group by far. Trauma had their own 12 bed ICU next door. So most of the “vents” I managed were “high turnover”. Frankly, we didn’t have the resources to have a lot of deathly ill people hanging around forever. We called families in right away. With extreme prejudice.
He has concerns that standard ventilator use may be over-pressuring COVID-19 patients’ lungs. He feels that this is more of an oxygen debt problem in COVID-19 patients and not like the typical ARDS situation.
Here’s a summary of what he’s saying in his youtube videos.
Anytime a lung is damaged, like the bowel, it “weeps”. Not in the airways so much but in the “interstitial space”, the space between the cells. That takes up room and the collapsible portion of the tissue is the airway. No airway, no ventilation. So as the process spreads from one small area it spreads to the entire segment, then the entire lobe, etc. what you end up with is a lung that looks and feels more like liver than sponge. Even if you can force air in there the pressure it takes to do so likely “pops” those portions of the lung at the top where the “air spaces” are generous because that potion of the lung is generally poorly perfused anyway, especially when standing up.
In my experience we never even tried PEEPS over 10 because once you have a low resistance “exit” from the lung you need a chest tube and after the chest tube is in you are ventilating the chest tube. I remember one trauma guy going to 12 of PEEP and we all cringed like he was defusing a bomb.
I can’t even imagine PEEPs of 15 or 20, much less 25.
I have posted about the old “urban legend” of Jet Vents. In the 80s there were TWO in the country. The idea of Jet Vent is it cycles so fast, ie, 100 breaths a minute or more, that what you are doing is setting up sort of a “standing wave” of laminar flow where you actually have air flowing in both directions simultaneously in two laminated streams. In my limited ICU time in 2005-6 era as a Family Practice time Resident I sort of “assumed” the modern vents had a similar capability. As an FP resident I had other fish to fry. Like how to fix a wrecked Pediatric Immunization schedule.
In any case one benefit of the “Jet Vent” is you could ventilate a lung at lower pressures. It’s best indication was “Bronchopleural fistula” where you have a direct, low resistance path OUT of the lung. IOW a standard vent is just ventilating the chest tube. A Jet Vent could theoretically ventialate a lung where the chest and airway itself were directly open to the atmosphere, so the lung could be ventilated at lower pressures. Which was sort of why I was asking about it in the first place.
This coronavirus chews up the heme in the red blood cells, releasing the iron.
Both the resultant lack of oxygenation and the iron roaming around the lungs, cause their own set of downstream problems.
Do any known bat coronaviruses attack heme?
is this the ER doc? Gas dr wrote a long critique of him. First of all ED docs do not follow their patients iin the icu and know nothing about vents. Second we don’t use PEEPS that high any more we switch to proning or inverse ratio ventilation, it proning in and of itself has problems. this guy had multiple red flags in his video....
If I had suggested frequent repositioning of patients on vents the nurses would have killed me. They rightfully freaked out over accidental extubation with repositioning for necessary procedures. Like an LP on a vent. Fortunately most Neuro patients on a vent have other places to easily obtain CSF.
My experience with ER docs is they intubate and bag on the way to ICU.
You should try reintubatiin a pro ed patients lying on your back in the floor. I e never done but I hear it’s a rodeo. Usually just have to take the time to flip them back over
The “old guys” in my field used to joke about the fun they had doing air pneumoencephalograms in the old pre CT days. They had a chair that was like you see in a flight simulator and was up in the air like 5 feet. To get the air to bubble up you had to position the patient in all kinds of different positions and to put the air in you had to be directly under the patient. The air stimulated the puke reflex. They said it was a nightmare, you’re down there, looking at the flouro, gently bubbling the air in, and the entire time the patient is vomiting all over you.
They got great pictures, though. They still put them in textbooks.
Here’s a near 20 minute audio discussion with the doctor. You can assess his knowledge and credibility far better than I can. I’d be interested to hear what you have to say if you have enough time to listen to it.
I suspect what he is saying is why I recommended “Hemosol” last week. We used it when I was an intern in a random controlled double blind study. It can work for a time but requires an FIO2 of 100% which the Type II pneumatocytes can’t stand forever.
Listened to about half of it. It’s a week old now. “Might as well be written on parchment” but does raise a number of issues.
In my days as a PGY-5 during my “year of Pediatric Neurosurgery” at that time there used to be a bunch of babies “rescued” by new tech in the Pediatric ICU. Premmies who (offhand I can’t remember what the details were) had “survived”. But due to the high FIO2s (or high airway pressures, which I always suspected was the real culprit) they had been exposed to they had “Subependymal hemorrhage of the ventricles”. Which led to “casting” of the ventricles with clot. Which led to hydrocephalus. Which was where we came in. You can’t put a VP shunt in a premmie. They have to “grow up some” to be big enough for a shunt. So my job, every morning, before I did anything else was to make my rounds of a half dozen or more of these premmies and stick an 18 gauge LP needle into their ventricle. Every morning.
The nurses were very grateful every time because they had been up all night with great anxiety over “As&Bs” (episodes of apnea and bradycardia) which immediately resolved when you deflated the baby’s head. It was a nightmare I obviously remember. Starting your day every day by basically sticking a nail in a bunch of baby’s heads. Great career.
But I did notice something he said and I believe I have seen it elsewhere. IF “Pulmonary Hypertension” IS “The Disease” we know that disease. The morbidly obese get it. Curiously VIAGRA is the treatment. I guess now we know why they nurse the patients “face down”.
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