High Flow Nasal Cannula (HFNC) to prevent intubation in COVID patients with respiratory failure?
High Flow Nasal Cannula (HFNC), (set at lowest flow to maintain adequate oxygen starutation), while thought to aerosolize virus particles, are being used in the US in patients with COVID-19 who cannot maintain oxygen saturations ≥90% with a NRB, and are included as weak recommendations in the WHO guidelines as well as the Surviving Sepsis Guidelines (our quick summary of surviving sepsis guidelines).
Here are some ideas on how to use High Flow Nasal Cannula (i.e. optiflow, airvo, etc) safely, that we’d like community feedback on:
What about combining a BiPAP Mask, feeding the HFNC through the 02 entry and then adapting the suction from an ordinary vacuum with a HEPA filter to the exhalation port?
VE grip with aggressive jaw thrust for BVM
We know that BVM can aerosolize virus particles, especially when bagging (which is generally not recommended in the COVID era), however BVM (as reviewed in Episode 140 COVID Part 4 Protected Intubation) is recommended as an option for pre-oxygenation and re-oxygenation after a failed first attempt. A key aspect of the technique to minimize the chances of aerosolization is the type of grip. The “CE” grip is the one handed grip which is not recommended and the “VE” 2-handed grip (with aggressive jaw thrust and the thenar eminences almost touching) is recommended (see image). Note that the majority of the force should up from the fingers directly up towards the provider (as apposed to pushing down with the thumbs)
Convalescent Plasma for critically ill patients with COVID-19?
False negative rate of nasopharyngeal swabs
Best predictors of survival in patients with COVID-19
Shorter shifts…or at least breaks?
Suggested algorithm for triaging patients in the COVID era
- First and second triage are decision points (not separate areas or people); define criteria for discharge ahead of time
- Clean area must be able to accommodate all levels of care (monitors, lab, procedures), and patients should all be masked
Are young people COVID-19 at risk for severe morbidity/mortality?
CDC data suggests that patients 20-44 years of age are not as immune to significant disease as previously reported and have up to a 20% hospitalization rate and comprise 12% ICU admissions. While mortality increases with age, among adults aged 20–64 years mortality is as high as 20% of hospital admission. However, children aged < 19 years generally have a good prognosis.
Coronavirus disease 2019 (COVID-19) hospitalizations,* intensive care unit (ICU) admissions,† and deaths,§ by age group — United States, February 12– March 16, 2020
End of life care for COVID-19 patients
Infographic from EM Ottawa Blog
Original article from CJEM https://caep.ca/wp-content/uploads/2020/03/EOL-in-COVID19-v5.pdf