This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

COVID-19 evolving indications for intubation

Hypoxemia and tachypnea should not be the sole indications for intubation, but rather a complete clinical assessment including work of breathing, mental status and increasing PaCO2 and/or acidosis. Based on experience in NYC, patients who present early in the disease course with oxygen saturations in the 80’s, but who are otherwise clinically well and relatively asymptomatic, do not require intubation. There have been suggestions that these patients may benefit from prone positioning and HFNC (see below). The recommendation early in the COVID pandemic to strongly consider early intubation in all patients with oxygen saturations <90% despite non-invasive oxygenation may not be the best approach.

Suggested stepwise approach to respiratory support for COVID-19

With surgical mask for all steps and negative pressure room for HFNC, CPAP, Endotracheal intubation where possible

Based on ED and ICU experience in New York, Level C evidence

COVID-19 graded respiratory support

Escalation of therapy based on work of breathing, mental status, PaCO2, VBG. Consider intermittent prone positioning.

Webinar on avoiding intubation and initial ventilation in COVID-19 with Scott Weingart

Respiratory support for patients with COVID-19

COVID-10 Hypoxemia on REBELEM

Suggested oxygenation strategies algorithm AIME

Oxygenation Strategies COVID

AIME Oxygenation Strategies COVID by George Kovacs & Adam Law

aerolization dispersion



By Lauren Westafer, FOAMcast

Prone position ventilation

Proposed mechanisms for prone positioning

  • Induces homogeneous compliance across the chest wall – Anterior chest wall – Weight of mediastinum – Improved displacement of abdomen contents
  • Better recruitment of posterior/dependent lung zone
  • May lead to an alteration of blood flow and better ventilation/perfusion matching
  • Improved drainage effect on respiratory secretions
  • Reducing ventral-dorsal transpulmonary pressure difference
  • Reduced lung compression
  • Improved lung perfusion

Consistently, most trials demonstrate improved oxygenation with ventilation in the prone position. One randomized trial and several meta-analyses also suggest a mortality benefit in those with severe ARDS. Trials have consistently shown that in most patients with ARDS (up to 70 percent), prone ventilation increases PaO2 allowing a reduction in the FiO2. Most patients who demonstrate a response do so within the first hour but delayed responses beyond that have been observed. The PROSEVA trial and several meta-analyses have reported mortality benefits from early, high-dose prone ventilation in patients with severe ARDS (defined by them as PaO2:FiO2 <150 mmHg). There is no evidence that prone ventilation prevents organ system dysfunction and reduces the intensive care unit (ICU) length of stay.

Sun, Qin, et al. “Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province.” Annals of Intensive Care 10.1 (2020): 1-4.

Restrictive fluid strategy for COVID-19 patients with respiratory failure

  • Aggressive fluid resuscitation should generally be avoided in COVID-19 patients
  • COVID-19 patients seem to be very sensitive to fluid overload similar to HAPE patients.
  • Consider norepinephrine at 5-10mcg/kg/min rather than a fluid bolus to maintain MAP>65
  • For hypovolemic patients give small crystalloid bolus (250cL) and reassess volume status frequently
  • Avoid fluid resuscitation to clear the lactate in euvolemic patients, as the high lactate is more likely a result of the catecholamine surge associated with severe hypoxemia and respiratory distress, than hypovolemia

Video for procedure of prone positioning

Webinar on avoiding intubation and initial ventilation in COVID-19 with Scott Weingart

Respiratory support for patients with COVID-19

COVID-10 Hypoxemia on REBELEM

Updated video on intubation tips and nuances using hyperangulated VL with George Kovacs

Sarah Reid’s take home points on COVID pediatric considerations

Andrew Morris updates

1.  Early experience with serum therapy looks promising.
2.  COVID Rheumatolgy registry shows patients who are chronically on hydroxychloroquine are still at risk of infection and death.
3.  We still don’t know “real” ICU mortality—because the various experiences are … varied.  China:  lots of non-vented patients.  Italy: catastrophic scenario.  England:  right-censoring of data means that they excluded patients on a vent for longer than usual.  For all: unclear about no. taken off vent for palliative or even rationing.
4.  Transmission routes –  Looks like pseudo-droplet spread in some manner.  Also looks like “infected” can reduce spread by surgical mask—which justifies asymptomatic population wearing masks to protect infecting others.  We don’t know if it will reduce acquisition.  The difference between public masking to reduce spread vs. reducing acquisition is an important one. Probably what motivates most people is not getting infected, but we don’t have great evidence masking will do that, and it probably de-emphasizes hand hygiene.
5. COVID-19 therapies – we are still lacking helpful information on pretty well anything.  More and more case series with different treatments.  None of them game-changing yet. Paper out of Australia suggests that ivermectin is theoretically effective against COVID-19 – jury is still totally out on that one, too. Read the full paper in Antiviral Research titled: The FDA-approved Drug Ivermectin inhibits the replication of SARS-CoV-2 in vitro:

CAEP suggested ED discharge criteria (based on Level C evidence)

1. Has access to food, water, communications, safe shelter
2. Is at baseline level of function
3. O2 saturation >94% on RA
4. RR<20, HR<110, BP at baseline or expected for age/sex
5. Does not appear clinically decompensated
6. Walk test: can walk 30 meters with <10% drop in O2 saturation (even if CXR or POCUS +ive)
Consider discharge advice for patient to perform walk test at home (ideally with O2 sat probe) and return to ED if O2sat<95%


Do you need an N95 mask when performing an NP swab for COVID-19?

Use of N95 mask is not warranted for NP/OP swab

  • There is no evidence that cough generated with NP/OP swab procedure leads to increased risk of transmission via aerosols.
  • HCW conducting this procedure should do so in a separate/isolation room, be well trained in the procedure, wear droplet precaution PPE, and request the patients to cover their mouth with a medical mask or tissue during NP swab.


COVID-19 pathophysiology and clinical features similar to HAPE: Should we consider HAPE treatments for COVID-19 patients?

High Altitude Pulmonary Edema (HAPE) and COVID-19 have many similarities:

  • Decreased ratio of arterial oxygen partial pressure to fractional inspired oxygen with concomitant hypoxia and tachypnea
  • Tendency for low CO2 levels
  • CT findings of ground glass opacities and patchy infiltrates
  • Elevated fibrinogen levels which are likely an epiphenomenon of edema formation rather than coagulation activation
  • Bilateral diffuse alveolar damage associated with pulmonary edema, pro-inflammatory concentrates
  • Lead to ARDS

There has been a suggestion to study the efficacy of proven therapies for HAPE in COVID-19 patients such as acetazolamide, nifedpine and phosphodiesterase inhibitors.

Solaimanzadeh I. Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19). Cureus. 2020;12(3):e7343.

COVID-19 protected code blue

Excellent overview: Protected Code Blue

Reuben Strayer’s video on protected transfer of cardiac arrest patient from EMS to resuscitation room

ED separation of COVID/Non-COVID is critical 

Completely separate
Separate entrance, exit; NO CROSSING between, fully independent of each other.
One way path through enter-assess/treat-out a different way (where possible)
Separate staff
Assign high risk staff (age, co-morbidities) to Non-COVID side. Even if an asymptomatic COVID patient comes there, the viral load will be lower, less change of transmission to others.
Whether you are in the COVID or non-COVID areas all staff and patients get surgical masks, social distancing and isolation where possible still applies.
Triage as COVID and non-COVID.

COVID-19 Lab Prognostication

Lab prognostic odds ratios mortality COVID

From MDCalc

Quote of the week

There are times when you can beckon,
There are times when you must call.
You can take a lot of reckoning,
But you can’t take it all.

There are times when I can help you out,
And times when you must fall.
There are times when you must live in doubt
And I can’t help at all.

Three blue stars rise on the hill
Sing no more now just be still
All these trials soon be past
Look for something built to last.

Built to last till time itself falls tumbling from the wall
Built to last till sunshine fails and darkness moves on all
Built to last while years roll past like cloudscapes in the sky
Show me something built to last or something built to try

-Jerry Garcia/Robert Hunter

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.