Understanding Care for Pulmonary and Critical Care Patients during the COVID-19 Pandemic

Female doctor washing her hands

Information on COVID-19 is evolving daily. The views and perspectives shared in this article are based on information from a webinar recorded on March 23, 2020. It has been edited and condensed for clarity and accuracy. This webinar was facilitated by J. Kevin Tucker, MD, chief of nephrology at Brigham and Women's/Faulkner Hospital, faculty director of accreditation and maintenance of certification for Harvard Medical School Postgraduate Medical Education, and assistant professor of medicine at HMS.

This interview features Dr. Rebecca Baron, a pulmonary and critical care specialist at Brigham and Women’s Hospital and assistant professor of medicine at Harvard Medical School, who discusses the approaches now being used to treat critically ill patients in intensive care units (ICUs).


Looking at the Wuhan and northern Italy experiences, what have we learned about which patients are most likely to become critically ill?

We’ve observed that elderly people above the age of 60, particularly those with underlying health conditions, seem to be at higher risk. That being said, there are increasing reports nationally of younger people without obvious comorbidities who are getting severely sick as well. So, even though we have information from our colleagues around the world, there’s a lot more that we need to learn about the characteristics of this virus and who is at most risk for adverse outcomes.

What are the danger signs that clinicians should look for in those patients who are already in the hospital? 

Working off our experience learned from Seattle and reports from our international colleagues, people may be symptomatic for five to seven days and then a large number will recover from those symptoms. But those who don’t, may then present. We are starting to see that patients may have what we call silent hypoxemia, meaning when they start to get sick, they need supplemental oxygen. These patients may not initially experience symptoms, but once their levels of oxygen support start to increase and they begin having episodes of hypoxemia, that seems to indicate a tipping point.

The overseas experience is that the sooner these patients who show signs of deteriorating receive critical illness support and even potentially earlier intubation, the better. Once they get to higher levels of oxygen support, not having emergent intubations aerosolized may be beneficial for patient outcomes and for the safety of healthcare providers. At least in the earlier phases of the disease, progressive oxygen supplementation requirements and increasing bouts of hypoxemia or dropping oxygen saturation are what we’ve been looking for.

Can you describe the typical clinical presentation or progression of illness in those patients you’ve seen at our institutions who require critical care?

The majority of the people we’ve seen so far who have symptoms are admitted in a negative pressure room until they’re ruled out. Fortunately, many of those patients seem to get better even if they are COVID positive and then are able to go home. But patients may come in for another indication and start to experience symptoms. If they’re not getting better, they tend to deteriorate fairly quickly. And again, this is mostly indicated by the progression of oxygen requirements and development of bilateral opacities in the lungs. Patients tell us that once the illness hits, it usually comes on with a roar.

Is there a typical progression of the radiographic findings?

There were initial reports of a typical radiographic appearance where CAT scans of the chest showed peripheral infiltrates. More recent data suggests that by the time we’re seeing patients who are ill, bilateral opacities in the lungs look fairly typical for acute respiratory distress syndrome (ARDS). I think the ongoing data collection will help us figure out if there is a typical early appearance of this virus.

 

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How often do these patients who become critically ill develop other types of complications, such as bacteremia and acute kidney injury?

In contrast to influenza, where super infection with MRSA (methicillin-resistant staphylococcus aureus) or bacterial infections are common, we’ve seen that bacterial super infection in this virus does not seem to be as pronounced. However, some groups from China reported that they did see fungal super infections. Obviously, we’re always vigilant for super infection. Many of these patients are immunocompromised for other reasons and are always at risk for super infection by other pathogens. 

Patients similar to those with ARDS and other critical illness do seem to have a significant incidence of renal dysfunction and may require renal replacement therapy. Early in the course, patients don’t seem to have hemodynamic instability. But later in the disease, sometimes even if they seem to be recovering from a respiratory standpoint, significant cardiovascular complications have developed, even so far as cardiovascular insufficiency that has been profound and the cause of mortality.

I’ve heard anecdotally that there seems to be a fairly high incidence of unexpected sudden cardiac death. Is that correct?

We’ve heard that it might even be as patients are improving that later in the illness they seem to have right ventricular dysfunction, and there are reports of sudden cardiac death. For those who don’t seem to be getting better, it is possible that they may progress to a multiple organ dysfunction scenario that, in some circumstances, results in sudden cardiac death.

I’ve heard anecdotally that there seems to be a fairly high incidence of unexpected sudden cardiac death. Is that correct?

We’ve heard that it might even be as patients are improving that later in the illness they seem to have right ventricular dysfunction, and there are reports of sudden cardiac death. For those who don’t seem to be getting better, it is possible that they may progress to a multiple organ dysfunction scenario that, in some circumstances, results in sudden cardiac death.

Is your approach to treat them as we do with many sepsis patients by giving high volumes of resuscitative fluids? Is that wise in patients who are likely to have leaky capillaries and may require renal replacement later?

The general approach we’ve been taking for managing these patients in our ICUs, in terms of fluid resuscitation in particular, is to err on the side of even to negative fluid balance. If people are hypertensive or in shock, they may need additional fluid resuscitation. But, if at all possible, we do not want to promote volume overload. Some of the reports from China suggest that early in the course of disease there is predominantly respiratory failure and less shock, but the report from Seattle suggests more of those patients may have had shock.

We are intubating patients once they start to show a progressive need for oxygen supplementation and that sort of silent hypoxemia. Patients do seem to respond well to supports on the ventilator that we’ve done for other ARDS patients, so we’re using strategies to support oxygenation while minimizing risk of lung injury from the ventilator. Other strategies such as prone ventilation seem to be beneficial as well.

For a typical patient with hypoxemic respiratory failure who is not in an ICU, we might start with something like BiPAP. Has that been successful in staving off the need for intubation in these patients?

Once patients declare themselves, they often get sick quickly. If they’re intubated later in the course, they may be harder to support on the ventilator. So, we want to try to err on the side of not doing noninvasive ventilation, first because it’s not beneficial to the patient and second because of the risk to healthcare providers of having a non-closed system.

That being said, I hope we don’t get there. But we’re all quite worried that if we get to our resource allocation crunch, we may not have the luxury of making that decision. Our colleagues in China have had to face difficult decisions of supporting people due to a lack of ventilators or other supports for patients.

Are there any final thoughts that you’d like to share with us?

Thank you to all who have reached out to help all of us as we care for these critically ill patients in our ICUs. We are so grateful. I hope we can speak again on the other side of this.


This interview is part one of a three-part series adapted from the Treatment of Infectious Disease and Immunocompromised Patients webinar recorded on March 23, 2020.