your "L-type" patient is someone with profound hypoxia but good lung compliance and not much alveolar collapse. i.e. the "happy hypoxemic." these are hypothesized to be due to V-Q mismatch.
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the "H-type" COVID19 patient is more classic ARDS with poor lung compliance & alveolar collapse. Patients often come in as L-type, some get well, some progress to H-type.
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when to intubate: watch the work of breathing more than the O2 sat. HFNC + awake proning, let the patient move around instead of lying flat on their back, and *watch* while being ready to intubate at any moment.
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transition to CPAP if HFNC isn't working. we're looking at high FiO2 and low PEEP, and also no added fluids. (logic being: lung recruitment isn't the primary problem, so pressure won't help; hypoxemia is severe and hypercapnia pretty rare, so more oxygen is better)
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"divorce FiO2 from PEEP" -- at least in type L. this is a *different* ventilatory protocol than ARDSNet, because these aren't typical ARDS patients. If you don't have collapsed alveoli in the first place, extra pressure can cause barotrauma.
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does remdesivir work? that recent NEJM study is SUPER USELESS FOR ANSWERING THAT QUESTION. (ed: just what I thought!)
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but ok, 57% of remdesivir-treated patients that were intubated got to be extubated, which is a lot higher than typical base rates. but hey, no control group, we don't know what to make of this.
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"as many of you have noticed, we have many COVID-positive patients." god i love the gallows humor. Clinical trial recruitment should be a lot easier these days!
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should you treat COVID19 pneumonia with antibiotics? dr. laughs, who's gonna send a person with CT evidence of pneumonia home without antibiotics?!
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Replying to @s_r_constantin
wonder if azithro is the standard for this use case or if it’s something else
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no, he says they usually give a combination of something like doxycyline and a beta-lactam, but you can give azithromycin if you want.
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