As one of the few interventions that's been shown to provide benefit to patients with COVID-19, mechanical ventilation is a major current focus in medicine. Hospitals are scrambling to get enough ventilators for their current and future patients, but they'll also need clinicians to manage them.
“I was actually astonished to learn that it's almost 50% of hospitals that don't have an intensivist who regularly rounds. I think that's one of the most challenging aspects” of the pandemic, said Curtis Converse, DO, a pulmonology and critical care fellow at Arrowhead Regional Medical Center in Colton, Calif.
An intensivist who helps cover some of these hospitals agreed. “Many hospitals may be confronted with providing mechanical ventilation to all those in need of this therapy, requiring multiple medical providers with the skills to run those devices,” said Bernardo J. Selim, MD, who works at Mayo Clinic's tele-ICU in Rochester, Minn. “Mechanical ventilation management of these patients could be challenging even for the intensivist.”
To help the hospitalists who may be faced with this challenge in the upcoming weeks and months, experts offered advice on how to manage ventilation in a crisis, or better yet, get training before hospitals hit that point.
Many hospitalists have had little education in this area, noted Dr. Converse. “Residency training, in general, doesn't do a lot of ventilator training. I think the majority of it is handled by the respiratory therapist and the intensivist. So people coming out of residency, they just don't have the experience to know which settings to adjust or particularly what settings to start somebody on when they're in respiratory failure,” he said.
Acute respiratory distress syndrome (ARDS) can be particularly intimidating to treat, and it's the most common reason that COVID-19 patients will require ventilation, Dr. Converse added. “It's right up there at the top, as a scary term to throw around if you're not used to managing ventilators or critically ill patients in general,” he said.
The good news, he said, is that there are some basic principles to follow. “Teaching low tidal volume, high PEEP [positive end-expiratory pressure] ventilation strategy is really important, like focusing on targets of six to eight milliliters per kilogram and a plateau pressure of less than 30 [cm H2O]. And then, if possible, trying to incorporate a driving pressure around 15 [cm H2O] or less.” (See FAQ article for additional details.)
Other experts warn that those without much experience in this area should only attempt ventilator management when there is no alternative. “Some of the basic things—patient assessment, the blood gases, understanding the safe parameters from mechanical ventilation—are all important aspects that people should understand,” said Richard Branson, MSc, a registered respiratory therapist and emeritus professor of surgery at the University of Cincinnati.
However, patients with COVID-19 can be particularly complicated to manage on a ventilator, he noted. “They have a higher requirement for oxygen . . . their lungs aren't as stiff as traditional ARDS patients. Some of them respond well to PEEP and some of them the PEEP gets too high pretty quick,” Mr. Branson said.
He hopes that physicians newly tasked with ventilation management can find help from a local expert. “The respiratory therapists at the bedside should be able to help them with setting the parameters without them having to become an expert on how the ventilator works,” Mr. Branson said. “I've been telling people this, if you've never had to take care of ventilator patients before, this is not the time to start. But with help from an intensivist, respiratory therapist and nurse, non-ICU physicians can be invaluable in monitoring and coordinating care on the critical care team.”
In some cases, clinicians may be able to get remote support. As a teleintensivist, Dr. Selim provides consults on intensive care patients for some hospitalists, but he gets more extensively involved for other hospitals. “In some smaller institutions, hospitalist groups may request a high-intensity monitoring tele-ICU support, in which the teleintensivist conducts video rounds in the patient room, taking an active and longitudinal role in the care of the remote patient, including changes in mechanical ventilation settings,” he said.
Hospitalists without access to that kind of help may want to consider lower-tech arrangements, such as a phone consultation with an intensivist at another institution, Dr. Selim suggested. Dr. Converse has looked into developing a hotline for such calls but noted several obstacles, including reimbursement and hospital privileging.
One common question hospitalists might have is about prone positioning, which has been recommended for patients with COVID-19 and ARDS. “Prone positioning has been known to improve outcomes in the sickest patients with hypoxemic respiratory failure, not related to COVID-19, and reports to date suggest patients with COVID-19 respond very nicely to it,” said Mr. Branson.
The problem is the difficulty of getting patients into the position and then switching them back every 12 hours, as is recommended. “That's not easy, and it takes a number of people and it can be physically taxing and it takes a lot of personal protective equipment,” said Mr. Branson. “We usually assign the respiratory therapist to hold the endotracheal tube. That's their focus to make sure it doesn't come out. And then you have three other people who are putting bedsheets under the shoulders and hips to flip the patient over on their stomach.”
Even after the patient is moved, care is more difficult in the prone position. “You have to use sedatives and paralytics a lot more liberally than you do in patients who are in a supine position. All the [nursing] cares are different, all the lines are going to come out backward,” said Dr. Converse.
Hospitals should develop protocols for proning patients based on available resources and expertise, Dr. Selim advised. There are extra complications to consider, including pressure sores, vascular line and endotracheal tube displacement, facial edema, and transient hemodynamic instability. “In addition, clinicians should be familiar with the absolute contraindications for prone ventilation such as unstable spine, open abdomen, or open chest (i.e., surgery or trauma), among others,” he said.
All that might be too much for some smaller or overwhelmed hospitals to handle. “I think it's a big ask to ask a whole bunch of staff to now get trained on this new mode of essentially treating a patient,” said Dr. Converse. “The data on prone positioning shows that facilities that are used to doing prone positioning and very familiar with the practice have better outcomes when they use prone positioning for 12 to 16 hours a day. The problem is that facilities that are not used to doing prone positioning tend to not have those same improvements and outcome and can actually have worse outcomes.”
Hospitalists should also be cautious handling the relatively simpler aspects of COVID-19 care, noted the experts. “If you have to intubate the patient, be careful. Make sure you wear all the right face and eye protection and avoid doing aerosol-generating procedures. Even a bag-valve-mask can be tricky—you don't want to be squeezing the bag and squirt the patient's secretions a couple inches away from the mask. Try to hyperoxygenate the patient with oxygen via nasal cannula and try to do the intubation as safely as possible,” said Dr. Converse.
If possible, get even farther away during intubation, recommended Dr. Selim. “When available, the use of video laryngoscopy is preferred in order to avoid direct laryngoscopy to distance provider from patient,” he said. Early intubation should also be considered to avoid the infection control risks of emergent intubation, Dr. Selim noted.
Starting before the situation is an emergency is also the key to hospitalists improving their ventilation management. “The best time to really practice your skills is probably before the onslaught of patients really hits,” said Dr. Converse. “Highly motivated hospitalists that want to learn how to manage ventilators and learn how to manage ARDS before they really start getting a whole bunch of patients with COVID-19 coming to their hospital will find those resources because they're readily available.”
Dr. Selim said that he's already noticed this happening, with his hospitalist colleagues “becoming proactive in learning prompt recognition of ARDS and use of lung-protective ventilation, as well as evidence-based adjunctive therapies,” he said.
Hospitalists with access to individual intensivists who can provide training should take advantage to learn as much as they can, the experts advised. Otherwise, video is a popular method for teaching these concepts.
ACP has produced a series of short videos offering basics of mechanical ventilation. Other sources recommended by the experts include the Society of Critical Care Medicine, CHEST, the American Thoracic Society, the Toronto Centre of Excellence in Mechanical Ventilation, and the American Association for Respiratory Care.
“They all have dedicated COVID-19 pages now, which I think is wonderful,” said Dr. Converse. “I think the challenge is going to be pushing that information out to people who aren't going to actively seek it on their own.”