FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc. and is in accordance with ACCME guidelines.

ALEX NIVEN: Welcome to the Mayo Clinic Critical Care Insights COVID Edition. My name is Alex Niven. I'm a consultant in the division of pulmonary critical care and sleep medicine here at Mayo Clinic in Rochester, Minnesota, and also the education chair for both our division and for the independent multi-specialty critical care practice.

The COVID pandemic has changed the way that we practice likely forever. And the critical care community has been particularly impacted by the current pandemic. Critical Care Insights COVID-19 Edition is intended for health care providers who are caring for patients with COVID-19 across the world in the ICU. Best practices to care for these patients have been rapidly evolving. And busy bedside providers-- I know I have-- struggle to keep up with the volume of information, especially given that the information sources that have been providing it are frequently less than rigorously peer reviewed.

In response Mayo Clinic has developed and asked Mayo experts COVID-19 task force that have collected and curated the available contents into a free public website under the Mayo Clinic Ask Mayo Experts COVID-19 Navigator. This source provides basically curated site for best practice recommendations in the care of COVID-19 patients, developed collaboratively by an interprofessional stakeholder group of Mayo Clinic sub specialists. And this information is continuously informed by rapid literature scoping reviews performed by the current Center for the Science of Health Care Delivery.

This online CME course is designed to speed dissemination and implementation of these best evidence-based guidelines, best practice innovation, and provide discussion of ongoing clinical controversies that we face in critical care as we take care of these patients. These discussions will feature the original authors of the contents that is available on Ask Mayo Experts and allow them to discuss the evidence and best practices that they have used to provide these recommendations and the why behind the information that they've shared.

We will be continuously updating this content as time goes on, based on the available high quality evidence that comes through our rapid scoping reviews and our evolving innovations and evolution of clinical practices within our own health care delivery platform here at Mayo Clinic. This initial CME offering consists of seven lectures, including topics from intubation safety, infection control, workflow considerations, navigating drug shortages, maximizing team performance, mindset training for the individual, humanizing critical care, respiratory therapy innovations, among others.

We will continue to evolve this content as time goes on with new information on the epidemiology, virology, clinical features of COVID-19 patients, and also evolving recommendations with regards to testing and the care in addition to infection control considerations in this challenging population. We hope that you enjoy this work. This information has been provided as a series of Grand Rounds presentations to our critical care community over the course of the last five weeks and will continue to evolve over time.

Welcome to Critical Care Insights. I hope you enjoy our work.

MALE SPEAKER: Good afternoon. Welcome to Critical Care Grand Rounds. I have a distinguished panel of experts that I think I'll let them introduce themselves, otherwise I'll mess up people's titles and things like that. Jenn, you want to go first?

JENN ELMER: Sure. I'm Jenn Elmer. I'm a critical care specialist [INAUDIBLE] ICU you here at St. Mary's, and also support the high consequence infectious disease program.

MALE SPEAKER: Excellent.

TODD MEYER: I'm Todd Meyer. I'm the director of respiratory care at St. Mary's.

STEVE HOLETS: Steve Holets. I'm a clinical specialist here at St. Mary's.

MALE SPEAKER: So we're going to change the way that we do Critical Care Grand Rounds in the town hall over the course of the next couple of weeks to focus on some of the practices that we have implemented since the start of the COVID pandemic that now have been better integrated into the practice environments. And the policies and procedures behind them obviously are constantly evolving as we learn more about the practice in the pandemic era.

And what we're going to do today is basically feature the things that respiratory therapy has been doing in response to the COVID pandemic in terms of both infection control and workflow. We're going to talk about the newly revised refractory hypoxemia protocol, which is, I think, particularly topical when it comes to caring for our COVID patients. And Steve Holets is going to talk to us about that.

And then recognizing that some of these patients may require prone positioning, and as our expected surge grows, we may be carrying for COVID patients in areas of the hospital that do not routinely prone patients. We also have Jenn Elmer to talk to us a little bit about the educational resources that are out there for preparation and training.

In the interests of being nimble, all the visual aids that go along with this discussion are basically housed with the policies and procedures under COVID Corner website. So if you have the COVID Corner website opened up now in a new browser window, if you want to click on the tab that says Acute Care Best Practices down about halfway down the page, the actual contents that highlights a lot of the things that we're going to be talking about here is available there and will serve as a visual aid for this presentation.

What we wanted to do was basically turn to the subject matter experts that generated a lot of that content to highlight the most important things and a little bit of the why. So with that, Todd, back to you to talk a little bit about the things that respiratory therapy has been doing for infection control and thinking about your practices.

TODD MEYER: Yes. We started using viral bacterial filters on both inspiratory and expiratory side of the HAMILTON-G5S. The respiratory therapists, when they're in the room, will do a visual inspection of those filters if they look wet. We'll replace them also. If you see your G5 starting to hold to auto PEEP, that's another great indication that the filters are soggy, and we aren't reaching complete isolation.

Also using inline suction, which is new for the practice on all patients, and that's again so the nurses or the therapists don't have to break the circuit to suction. For transporting these patients, the HAMILTON-T1 ventilator-- the red one everyone sees-- again has an inspiratory/expiratory filter on it. We'll also leave the inline suction in place and add another filter between the suction and the circuit. That way if we have to break the circuit to transfer the patient, we'll contain aerosal that way as well. And the vents should also be put in standby mode during these transfers, again, so we're not spraying the room.

When it comes to non-invasive ventilation, we're filtering the expiratory outflow of the circuit. We're also putting patients on total face masks to help eliminate leakage possibilities. And we've all seen the full face mask on the model. They're slide down. The total mask is a better seal, easier for the patient as well for comfort.

The other thing we're doing is-- you've probably seen MDI therapy is scarce in the Mayo Clinic. There's a shortage. So everyone is using aerosol therapy. And we're using breath actuated nebulizers that are set to only deliver medication on inspiration of the patient. And we're also again using that bacterial viral filter on the expiratory side of the nebulizer.

MALE SPEAKER: Can you tell us a little bit about these filters in terms of how effective they are in terms of filtering viral particles?

TODD MEYER: So 99.99%.

MALE SPEAKER: So really the biggest issue when it comes to mechanical ventilation, then is breaking circuit breaks [INAUDIBLE]. And that's the biggest issue. And just to reiterate what I heard, and make sure that I'm understanding things right, so whenever the circuit is broken, you're trying to put the ventilator on pause.

TODD MEYER: Yup, or standby.

MALE SPEAKER: So there's-- minimal or standby mode, so that there's minimal airflow. And then the other thing that I wanted to ask is, what do we do if inline suction becomes soiled? It's been a long time since we thought about inline suction. So what's our practice and policies when it comes to that?

TODD MEYER: So we're going to leave them in place until they're soiled or don't function. And then again you'd have to place the patient at standby mode-- quickly switch that suction out. If you have to hand ventilate the patient, again in the room is the filter already attached to the self-inflating anesthesia bag.

MALE SPEAKER: Perfect. So you've talked a little bit about nebulizer and nebulizer practices already. Could we talk a little bit about high flow nasal cannula and non-invasive ventilation? By the way when you say the full face mask, you're talking about the fireman mask, right--

TODD MEYER: Yes, correct.

MALE SPEAKER: --the one that covers the entire face?

TODD MEYER: Yep.

MALE SPEAKER: Perfect. So practices-- we all know people who have good mask seals and not-so-great mask seals. I know this borders a little bit into IPAC. But I'm pretty sure you've got infection control practices for that burned into your brain. When you walk into a room with somebody who's on non-invasive ventilation, what's the protective posture? And what are the things that you guys are thinking about to minimize aerosol generation?

TODD MEYER: So in the non-invasive population, again the filter on the side to minimize aerosolization into the room. I think-- Steve, correct me if I'm wrong-- we're calling that an aerosol-generating procedure. And you should be using an n95 and the appropriate PPE when we go into the room when the patient's on that device.

MALE SPEAKER: And so we're thinking airborne precautions in that setting?

TODD MEYER: Right.

MALE SPEAKER: Perfect. Steve, things that you want to add when it comes to a noninvasive and [INAUDIBLE] were part of that too.

STEVE HOLETS: Yeah. We all know that there's no way to totally filter those systems, particularly the high flow nasal cannula. But we're doing the best that we can with those. I think again if we be very careful and do the correct PPE, we'll be as safe as possible.

MALE SPEAKER: Perfect. So, Steve, let me turn to you to ask a little bit about refractory hypoxemia. So at least what I've read in the literature in terms of the bad COVID cases-- and again, we're thinking 20% of COVID patients potentially are going to develop symptoms bad enough to potentially warrant hospitalization, and maybe 5% of that 20% is going to require intubation-- or 5% of the total-- so it seems like what a lot of people are describing is fairly significant hypoxemia in these patients and individuals who are going to be on a ventilator for a reasonable period of time, although what a reasonable period of time is-- 10 to 14 days, somewhere in that window-- is still kind of a moving target.

So can you talk to us a little bit about the initial approach to these patients and how we've translated our standard hypoxemia protocol and modified it in this situation?

STEVE HOLETS: Sure. I think what's really nice is we're ahead of the curve. Our refractory hypoxemia protocol that we put into play what five years ago now is really paying dividends, in that we already know what's best for these patients as far as they are very responsive to PEEP. And they're very responsive to prone positioning.

We've modified our-- the latest version of this is just based on better evidence in that we're going to try to implement this stuff sooner. So as far as recruitment and higher PEEP, we want to do that much quicker. In the original protocol, we said two hours. Now we're saying 30 minutes. So there's no reason when you intubate them-- that's a perfect time to see if they're-- to find the best PEEP, to recruit them if you need to recruit them and get them going down the road right away.

And what's really amazing is like you said, these people are very hypoxemic-- is one of the trademarks-- but they're also very responsive very quickly. So we can turn them-- if we do it quick, we turn them around quick. If they are truly refractory hypoxemia, then we-- I'll back up. One thing we did add on our original page too, the first page, was we added driving pressure. So we're monitoring driving pressure and keeping that under 15. That's added in there. If we don't--

MALE SPEAKER: Actually, Steve, could I interject for a second?

STEVE HOLETS: Sure.

MALE SPEAKER: Just because I'm a simple knuckle dragging pulmonologist who doesn't live and breathe this stuff every day. So in terms of just starting vent settings and the tools that we have at the bedside, so low tidal volume ventilation and using the PEEP table that we have hanging off the ventilator, tell us just a little bit about that just to remind us.

STEVE HOLETS: So we're using low tidal volume ventilation based on predicted body weight, maintaining a plateau pressure under 30, a driving pressure-- which is plateau pressure minus total PEEP-- under 15, and then for guidance for PEEP, actually we're putting a new high PEEP FiO2 table on there, which will give you a higher PEEP and lower FiO2. And that's been shown to be beneficial in the moderate to severe ARDS patients with a PF under 150.

And that really works well. If they're still refractory hypoxemia, we turn the page. What we've been doing before still works as far as recruitment or possibly putting in an esophageal balloon to see if we need even more PEEP outside of what the P/V tool says. This is important, especially in the patients that may have chest wall stiffness.

When we get through that, pretty much the same thing. That works-- higher PEEP. And prone positioning works. And I'll let all that Jenn talk about that. We have eliminated some of the rescue stuff on the right hand side that showed don't benefit the oscillator because we don't even have that in the inventory anymore. When we do do the proning, we try to get ECMO involved right away, at least give them a heads up that this may be a potential. And I don't think any of our patients have had to go to ECMO.

MALE SPEAKER: So I'm going to highlight just a couple of things in terms of what you said because we know from our own internal data that we're pretty good at low tidal volume ventilation. But there's always a little room for improvement. So we try to make things as easy is as we can, especially when you're in a difficult situation-- all dressed up in PPE-- in terms of putting all the information front of you at the bedside.

So we've got those cards with the pink and the blue that basically gives you ideal body weight based on the height that we measure on everybody when they come in the hospital. And then you can actually pick out from the table what 6 ccs per kilo is, rather than having to do the math. So it sounds like you changed the PEEP table that used to be the [INAUDIBLE] low PEEP table to the high PEEP table. So we should anticipate that we're going to see slightly higher levels of PEEP for the FiO2 than we were used to seeing before.

And that's our starting point. And then we're going to be adjusting down on our tidal volumes to keep our plateau pressure less than 30 and our PEEP to plateau difference that we're using volume target ventilation less than 15. What are we doing with neuromuscular blockade?

STEVE HOLETS: That is still-- and that's a good question. What's really interesting on these patients that we've seen and talking to people from the east coast in Italy is these people seem to be very responsive to high work of breathing, meaning that if you let them breathe too much, they crump again. I think neuromuscular blockade early, if they're breathing hard, is definitely the thing that we should still consider, or heavy sedation.

MALE SPEAKER: Yeah. So the key here I think is to make sure that when we talk about a lung-protective ventilatory strategy using all the criteria that you have-- and by the way this table is provided under the refractory hypoxemia link on the COVID Corner, so if you're having trouble following along, the algorithm is right there-- really the idea is this lung rest period. And so to measure PEEP and plateau pressures and all that stuff, we need a patient who's passive and breathing comfortably with a ventilator. And then if we still think they're exerting significant respiratory efforts, then that's where paralysis comes in.

So there was a couple of questions that came in while we were talking there. There was somebody who was asking about if we anticipated seeing a resurgence of the adult oscillator. And I think you've answered that question. So the answer to that is no.

Let me jump back a second because there's a question here about noninvasive as well and asking about the helmet versus the fireman's mask. So just in terms of background for those who might not know this-- so there are a few studies out there that are pretty interesting, positive trials in terms of using like a space helmet that clamps down at the neck instead of a mask in patients selected patients with ARDS.

I know there's been a little conversation. But I don't know if there's any conclusions about it. This helmet's not FDA approved yet.

[INTERPOSING VOICES]

TODD MEYER: Not the ones you see in the study. The helmets you see on the news are actually the helmets from hyperbaric chambers that patients wear-- they're for wound care right. That's how they get the flush and--

MALE SPEAKER: So that's to concentrate the oxygen rather than to put on pressure?

JENN ELMER: Yeah. So those helmets are made for hyperbaric chamber. As you see from the news articles, some sites are used to drive CPAP. They'll drive high flow oxygen into the valve and then have an adjustable CPAP valve on the outside.

MALE SPEAKER: So right now they're not on the table for us?

STEVE HOLETS: No. The other thing is I like the concept of the helmet. I'd love to do a little research on it. It's promising. But from a logistics standpoint, because of the dead space in the helmet, it takes at least 100 liters a minute continuous flow. So we would be using an awful lot of medical grade gas. It also takes probably one of our high end non-invasive ventilators, which is going to be our first line of defense when we lose ICU vents. We use those as invasive.

So I don't know if the benefit outweighs the other end of it-- the logistics of it. I don't think we can run that much gas. And then if you've watched the news, they're talking about this helmet-- they're made in a garage. And they just are producing enough. So it's a learning curve to use them. And I don't think we get enough of them and have enough time to train people to use them properly.

MALE SPEAKER: I think you lost me at made in a garage.

[LAUGHTER]

So in terms of all that sequence-- and there's a lot there-- timing-- because I want to turn to Jenn here. And we know that basically if we're going to prone patients, we need to rattle through the basics in a reasonably timely manner because early initiation proning is the thing that's going to maximize the benefit. So what's the timing that you have in the new algorithm?

STEVE HOLETS: It's 30 minutes for the first page. And we want probably an hour or so for the second page. If your initial stuff doesn't work, don't wait. Move quickly. And then our algorithm there is proning on innovative patients. I have a lot of interest. And I see no reason why we're not considering-- and we are talking about it-- proning nonintubated patients. There's no reason not to. If you look at the [INAUDIBLE] definition in the fine print, they don't have to be intubated anymore. And if you follow all the professional association guidelines, proning is in there. So I'm going to let Jenn talk about that some more.

[LAUGHTER]

MALE SPEAKER: So we got rid of isolation. We don't have jet ventilation anymore. I don't know what you did with inhaled vasodilators and the protocol. I'm sorry I don't recall that. Is that off the table or is that still there?

STEVE HOLETS: That's a rescue.

MALE SPEAKER: It's a rescue. And then we've talked about the fact that there are separate ECMO practices that we're not going to talk about today. But that's actually the top topic on the COVID Corner, if you want to see the current guidance for ECMO selection. But out of all that stuff, really the thing that's most evidence based is proning. So I'm going to turn to the subject matter expert when it comes to proning and talk a little bit about how you stood up your practice in the NICU-- if you don't mind me turning back the clock a little bit first-- and then what available resources are out there for units who are concerned about potentially ramping up their services in their individual areas.

JENN ELMER: So there are a lot of ways to prone patients. We have developed a way over the last five to seven years now-- five years at least-- to manually prone patients in the beds in the ICU. [INAUDIBLE] and [INAUDIBLE] have a lot of experience with this-- do this on a regular basis for our patient population. Because it's such a cyclical thing, and not everybody has had exposure to it, we did create step-by-step procedure guides online. And those will be included in [INAUDIBLE].

We have a preproning checklist and an as-you're-proning checklist. And we've included a step-by-step video that would show people how to do this real time. [INAUDIBLE] all those resources direct patients for proning patients that are intubated. Andrea Lawrence and I, who created all these materials, have worked with other sites that might not have the same beds that we have or have different equipment that we can work through on an individual basis with [INAUDIBLE] sites that have a little bit of different equipment or beds or have some nuances that they'd like to talk [INAUDIBLE].

Like Steve said, we're working through processes of manually proning patients that aren't on any kind of a ventilation. And some of it's just literally having the patient lie on their side by themselves in a comfortable position. We do have some suggestions that we're working on how to make that comfortable and placing pillows and reducing pressure points that tend to make it more comfortable for a patient [INAUDIBLE] to self prone or for us to manually prone patients that are non-invasive or high flow nasal cannula.

MALE SPEAKER: And I need to be careful with that because certainly proning patients without an endotracheal tube in is not our standard practice in any way, shape, or form. So I think there is a research protocol that has been submitted. And so we want to make sure we draw a clear line between what we will consider standard practice and what really should be done in an organized fashion in terms of a research study and investigation. But I think it's important to discuss the topic because certainly with the changing criteria for ARDS, now this sort of stuff is on the table.

STEVE HOLETS: I think we want to do the research on it. But I think it's also something that clearly helps. There's actually going to be an article published I think in the [INAUDIBLE] shortly.

MALE SPEAKER: You're going to get me in trouble with the research people if you keep on saying stuff like [INAUDIBLE].

[LAUGHTER]

Let's put that top to rest for now. So just to highlight a few things that you talked about, Jenn-- so in terms of the training resources, we have those actually at the top of the critical care education page right now. So those of you that are following online, you can just click on the education link at the top banner of the page. And we have all of that information under the Grand Rounds section. We'll also add a link to that after this down in the refractory hypoxemia area of the COVID Corner.

So, Jenn, can you tell us a little bit more? So we've got we've got you and Andrea and a host of other people who have experience with this. If there are units that want to ramp up a program, what sort of training opportunities-- how do they go about doing that sort of stuff-- because you're doing just a few things nowadays. And I'm going to guess Andrea is to.

JENN ELMER: I would say using those online resources was probably the best training. It's hard to do an in-person training without mannequins and other things like that. Most of our training comes on when you're doing it with in-person resources, whether that be Andrea or myself, or one of the charge nurses from [INAUDIBLE] definitely can be in-person resources at the time of need as well. But reviewing the protocol, reviewing the checklist, and reviewing the videos are probably the first initial steps for [INAUDIBLE].

MALE SPEAKER: So this is maybe a little bit of an out-of-the-box question, understanding that our simulation resources are somewhat limited now because of infection control practices and all that, but are there are there any sort of practical things that we could suggest to people because we know that the hands-on practice is probably best-- bed roll or something like that, is that worthwhile doing, or should we just wait and go through the steps until we actually get a patient?

JENN ELMER: We've had other units tell us that the online resources have walked through real-time proning when they haven't had experiences. So while I simulation is a great option, I don't know with our time resources, and our space resources, we're at that luxury. But from the feedback we have received that the videos and the checklists walk through people step by step on all issues.

MALE SPEAKER: And, Jenn, I'm going to I'm going to keep on with you because we're moving a little quickly through our agenda. And I don't have any other questions right now on the Slido queue. Can you talk a little bit from a nursing perspective in terms of the experience that you guys have had in [INAUDIBLE] and some of the things that you've been doing in terms of adapting to COVID patients or COVID [INAUDIBLE]?

JENN ELMER: Sure. I think the biggest thing is PPE. And that's the biggest, like Dr. Brown talked about earlier. And the question that most people have-- especially if they're new into taking care of our COVID patient positive or our COVID rule-out patient-- and really being mindful of taking your time and buddying together. We have really buddied those patients that we have on modified droplet or are undergoing an [INAUDIBLE] procedure that need special PPE, that we're buddying with people that going in the room and coming out of the room, so they feel safe with their PPE. And they know the proper procedures of taking it off in a safe manner.

I think buddying and taking time and taking suggestions from each other and knowing when it's OK to stop and slow down and make sure we're doing things safely-- I think when it comes to codes, those are important things too, that it's part of our nature to slow down before going into these patient rooms. But that's the key, is making sure everybody's in the proper PPE before taking care of an emergency [INAUDIBLE] whether it be COVID or otherwise.

Communication systems are probably the other key thing, really working through the different communication ways to talk with providers inside and outside the room and patients inside and outside the room-- talking to that patient in there without having a team of people going into that patient's care room, whether that be the In Touch video system-- which is probably the most sophisticated part of the communication-- whether it's using the call light system to talk it into the patients--

MALE SPEAKER: Can you just tell us a little bit about In Touch-- what that is and how it works?

JENN ELMER: So In Touch is a connected-care platform that's commonly used in the EICU. They've been gracious to help us set all that up, and basically a tablet communication system that we can video and audio into the patient's room, talking to the care providers in the room and/or the patient as necessary with a connection to a desktop or mobile device outside of the room.

The other thing from a communications standpoint has been Zoom. And that was one of the approved areas of being able to talk from a family member to a patient inside the room. So working through some of those ideas of how to keep patients connected and how to keep family members connected with their loved ones. So we talked about the In Touch and the Zoom technology, using a tablet-based feature inside the room, and also the call light system. The call light system is basically like a speaker phone that you can use right with inside the room. So we've got some guidance on how to do that.

Using the regular old analog phone in the room has also been key to be able to communicate inside and outside the room. And knowing that you can actually talk through these doors and hear people if you're standing up against the door and talking to the provider in and outside the room, to make sure that we're addressing needs. We write notes to each other of things that we need, whether that be on a window or a piece of paper to share, these are the things I need the room the next time somebody comes in or this is what I need passed in.

The things we've worked on as lab draws and really minimizing people in the room and teaching nurses how to do blood draws [INAUDIBLE] front lines that they might not typically do, and how to pass those in and out of the room in a safe manner. Those are the top things I can think of what we're currently working on.

MALE SPEAKER: Yeah. And that's fantastic. And that's a lot.

JENN ELMER: Sorry, and I talked really fast.

MALE SPEAKER: No. It's perfect. But I know that there's a lot of interest in terms of how we're going to generalize these practices. And I know you're working on that [INAUDIBLE].

So I have I have new questions. And I think we'll take a pause here and answer some of these questions. And I think somewhere along the way we need to talk about your efforts to move the ventilator control panels out of the room because we haven't mentioned that yet here. But why don't we start with a hot topic on social media that I know Steve might have a thing or two say about? So the top question right now is, what is our thoughts in terms of ventilating multiple patients on a single ventilator? And would we see this in a worst case scenario? Steve.

STEVE HOLETS: We would only see that in the worst of the worst case scenario. I was actually on part of the task force that helped put out the multi professional organization statement against this. If you read the statement-- and since then some organizations have backtracked a little, saying, this is the last of the last resort. It's my worst nightmare. From perspective pulmonary mechanics, it simply to me can't be done safely.

You might get good gasses. But everybody's lungs are different. There is no way that you're going to put multiple patients on a single ventilator and do the safe guidelines that we do now. And who is going to suffer the most will be the healthiest patient with the most compliant lung.

MALE SPEAKER: So can you can you spell it out for me, just so it's clear? So I've got a patient who's got sick lungs on one ventilator-- or on one end of the ventilator-- and somebody with compliant lungs on the other end. So where's the air going to go?

STEVE HOLETS: To the most compliant lung. So even though the protocol that's put out there says use pressure control of 15, so a driving pressure of 15, you're going to try to get everybody's saturation to a point-- so you're going to use probably higher FiO2s and higher PEEP than the healthiest person will even ever need. So all the ventilation is going to go into that lung.

Now they proposed to try to match patients. And I've done RT for 35 years. I don't think I can match four patients with the same compliance.

MALE SPEAKER: Is your ideas even if you do match people, their compliance is going to change patient to patient over the course of the shift?

STEVE HOLETS: If Jenn turns a patient, if the secretions build up in one ET tube, any of that's going to change where that gas is going go. Again I feel very sorry for our colleagues in New York. And I know that they're just grasping at anything to keep people alive. But I worry that this may cause more damage than good in the end.

MALE SPEAKER: Because basically the person that needs it isn't going to get enough ventilation and pressure, and the person doesn't need it it's going to get over ventilated and potentially have ventilator-associated lung injury [INAUDIBLE].

STEVE HOLETS: Correct.

MALE SPEAKER: So the next question of the queue I'm not sure if we have the authoritative answer for. But I'll just throw it out to the group. There's a question about sedation supplies. And apparently other locations are reporting shortages in sedatives. I don't know anything about that. So I think we'll table that question right now and bring that back to our pharmacy colleagues to potentially answer.

So there is a question here in terms of if we would do anything different in terms of how we prone somebody with COVID-19 compared to how we normally do it. Jenn, any thoughts there?

JENN ELMER: There's definitely a lot of options out there. There's a lot of ways to do this. I think the question might be driven that our current protocol takes a fair amount of people to be able to do well. We feel like the current protocol is our best option, if all things considered, we're able to do that. Because of the pillow system we use, we're able to allow the diaphragm and the lower part of your lung to expand a little bit more.

If you go to the original trials in the French video, they really just turned the patient over the bed and have their face right on the bed without anything underneath them. There are probably advantages and disadvantages to both. Would we be open to doing different things? Absolutely. If we have the resources we do, and we can continue to do our current process, I think that's reasonable as well.

STEVE HOLETS: I think that's good.

MALE SPEAKER: I guess-- because the next question on this is asking if we should just encourage our patients to sleep on their stomachs. I guess that's probably worthwhile highlighting the reason why proning milder patients is still an open research question. So when we think about the class of studies that informed our practice with proning, it was really only the folks that were in the severe category that drove the benefit in those trials. So that's the reason why proning milder patients is still a little up in the air. So again I'm just going to highlight that that's still a research question for us.

So is there guidance on if, when, and for how long we let someone with COVID-19 try a spontaneous breathing trial or try a spontaneous-- well I'm going to change this question because this is another one talking about spontaneous breathing in prone proposition without an endotracheal tube in place. It seems to be a popular topic this week.

But let's talk about anything that we would do differently in terms of timing of intubation and timing of extubation because I know that's been a hot topic both in the United States and abroad. So should we be intubating these folks more aggressively because of the closed circuit and the reduction of aerosol generation? And then should we be more cautious in terms of extubating these people, recognizing that we're also going to generate aerosol when we extubate these folks to noninvasive or extubate these folks to high flow, which is a practice that we've done more and more in recent years, showing that the data suggests that's better in people with underlying cardiopulmonary disease. So what's the conversation been on that?

STEVE HOLETS: I think as far as noninvasive and high flow on the front end of things, I think the evidence is pretty clear that this moves very quickly. And we've seen in the few cases we have that these patients deteriorate very quickly. So I wouldn't give the-- before we talked about give them four hours or whatever-- I think it's more like maybe an hour. And then you have to watch them closely.

If they look like they're wearing out or breathing a lot-- hard work of breathing-- it's time to intubate it. Don't doddle. I think the Italians only have about 20% success with their non-invasive on these patients, which is pretty low. Once they're intubated, we don't want to keep everybody paralyzed forever. And we try to wean these patients.

But the other thing that's remarkable or really stands out on these patients is this isn't normal ARDS, where they're recovering, now we're going to wean them, and we'll get them off the vent in a couple days. Again the Italians' time is 10 or 12 days on the vent. And what we've seen is when you start letting these patients breathe, they may look good for a little while. But then suddenly they'll relapse. And when they relapse, they desaturate quickly again. So we really need to watch our work of breathing and have clear cut goals for what's failure and when to resedate or take over and unload them so they're not breathing so hard.

MALE SPEAKER: I think the guidance that we have on the website-- I haven't quite committed to memory every word-- is one to two hours, just to highlight that we don't want somebody sitting there laboring on noninvasive-- potentially struggling with a poor mask seal-- if we're not capturing that person early. We need to intubate them early because-- and this will be a topic for future conversation-- we have our first draft guidance up now in terms of intubation practices. But that's probably one of the highest risk procedures we're going to do. And we'd like to do that in a controlled manner, rather than do in a crushed airway if we can.

And I think for me when I look at the stuff that's out there, it seems different places have different practices in terms of intubation. I think our approach is pretty pragmatic and right in the middle when it comes to that. For me it seems like a lot of other reports in terms of the persistent hypoxemia and the rapid decline isn't that different from a lot of other types of viral pneumonia. So you know metapneumovirus, a lot of those folks have significant [INAUDIBLE] and things like that over time. Just these folks seem to be sicker and obviously we haven't seen it before. So it's a lot more people getting sick.

So there's a comment here about pediatric and neonatal contingency plans. And I'm not sure if-- I certainly can't address those things. Can you guys talk about ventilator aspects for pediatric and neonatal at all? Or is that in a separate category, and we'll table that for another time?

TODD MEYER: I think that group should speak on that.

MALE SPEAKER: Yeah. So we'll let that go for right now. So neuromuscular blockade-- so early evidence of neuromuscular blockade for 48 hours in the ARDS was not replicated in subsequent trials. Do patients need neuromuscular blockade for prone positioning? That's a good question.

So certainly the [INAUDIBLE] trial was now nine years ago, when it was published. And we've got the [INAUDIBLE] trial that was published about a year ago now. I'm losing tract. It was sometime last year. And that showed basically not a clear difference in terms of folks with ARDS and neuromuscular blockade. So differences in that trial-- there was a lot of folks that were excluded because they were already on neuromuscular blockade. There was also a lot less sedation used in both arms in the [INAUDIBLE] trial, compared to the [INAUDIBLE] trial.

So I'll just ask your experience-- because this is an evolving topic that I think that there's a lot of opinions on-- what have we seen in the NICU over the course of the recent past since those trials were published?

STEVE HOLETS: I think the neuromuscular has come down some-- the use of it. Now they don't need to be totally paralyzed either. I think the best tool you have in the room to adjust a neuromuscular blockade is a ventilator. And again we know that we can't allow these people to generate high transpulmonary pressures. And the ventilator will tell you when they're breathing too hard. And if they are, then you need to reinstate whatever you need to reinstate to stop that because that's what's causing the damage.

MALE SPEAKER: Well said. So for me it's been a little liberating to allow me to use a little bit of clinical judgment. So if people are well synchronized with the ventilator, by adjusting my ventilator and using plain old sedation, I get away without neuromuscular blockade. And then the neuromuscular weakness and concerns with that that come along with it. Jenn, your perspective at all?

JENN ELMER: Similar. What nurses worry about is the patient moving in and disrupting our positioning. So just keeping those things in mind of a sedated patient, as long as that works with the dyssynchrony and with [INAUDIBLE] with that position [INAUDIBLE].

MALE SPEAKER: Yeah. I think I might take this next question. So this question is, should we allow permissive hypoxemia as long as there's no signs the symptoms of inadequate oxidation, like organ failure, acidosis, or altered mental status? And should intubation ever be driven by sats alone? So I think the challenge here is what's an adequate oxygen saturation? And really what we worry about at the end of the day is just an organ perfusion and an oxygen delivery.

I think from a personal standpoint, I've been thinking about when I'm going to draw blood gases and what the real hard and fast implications of that are, recognizing all the important things that Jenn was talking about before in terms of limiting ingress and egress out of the room, the number of people who have to go in there, and then just with the return on investment and our risk is in terms of labs.

So certainly we have end-tidal capnography that we can use in many rooms to help guide end-tidal CO2. Maybe we can spend just a minute or two talking about that, so advantages and pitfalls of using capnography in the ICU. Anybody.

STEVE HOLETS: Depending on the device we use, we have then it will have to filter that also. So then we come to another filter in the circuit.

MALE SPEAKER: So that's more dead space, more resistance, so that's an issue.

STEVE HOLETS: Right. Plus dependent on the type end-tidal, it'll pull gas and dump it into the room. So we have to filter that before it dumps--

[INTERPOSING VOICES]

MALE SPEAKER: --that get's really complicated. I hadn't thought about that. And then obviously if you've got somebody who's got underlying lung disease, then what you're measuring with that end tidal is going to be less and less accurate in terms of what your true [INAUDIBLE] is. So then if we see reasonable minute ventilations and stable minute ventilations, and we assume that the VQ matching is pretty stable, that's probably going to be our best bet in the short term for this.

And then for oxygen saturations, we certainly know that we put supplemental oxygen on everybody, that's a super controversial thing, whether or not that juice is worth the squeeze at all. I think probably using saturation is a reasonable guide in reducing the [INAUDIBLE]. Have you guys seen any alterations in the practice over the course of the last couple of weeks in the NICU?

STEVE HOLETS: I don't think I have really outside of should sats drive intubation. Again when I think about spontaneous breathing, if somebody is-- I don't care if they're sat looks marvelous even on a low FiO2. If they're working really hard, it's not a good thing. You're heading in the wrong direction.

JENN ELMER: I would say outside of the COVID discussion, we're working on a hyperoxia project to try and minimize the use of oxygen [INAUDIBLE] do this as well.

MALE SPEAKER: Yeah. So we think we can probably be a lot more conservative. We can certainly cut back a lot on blood gasses. And I think following sats and [INAUDIBLE] ventilation on the ventilator is a good place to start. We still haven't talked about the cool things you guys have been doing in terms of moving the control panel from the ventilator out of the room. Can you talk about that for a minute?

TODD MEYER: So there are some devices on the market, especially in Europe, you can adjust with your iPhone. That's not in the US. So they have to be tethered. So we can move the HAMILTON-G5 screen off the ventilator body. Uncoil the cable and mount it on an IV pole outside of the room, which is great. A little bit of PPE entrance in the room, there are some pitfalls, as Jenn and I have talked about.