Editors’ Note: This article was accepted on April 14, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.
Explore This IssueACEP Now: Vol 39 – No 05 – May 2020
I recently spent 10 days at New York City’s Bellevue Hospital, treating patients suspected of having COVID-19. Here are some of the things I learned about managing these patients.
Position, Position, Position
The first thing to appreciate when people come in with severe hypoxia is just how much boosting fraction of inspired oxygen and positioning maneuvers help. The first thing I do is sit them straight up and put a nasal cannula on them, preferentially with a bubble jet humidifier set at 6 L. This is a small bottle of water that fits between the oxygen wall connection and the nasal cannula, and provides humidification. If you avoid intubation, these patients are going to be on oxygen for a long time. If you run high-flow nasal cannula through a standard cannula without humidification, it gets uncomfortable and may injure the mucosa. I then take the nonrebreather mask and put it over that. Part of the reason for the non-rebreather is for covering their mouth (decreasing aeroslization).
The advantage of combining those two is you’re now at 21 L minimum if you’re at 15 on the nonrebreather, and you can crank that even higher (although the manometer will only tell you it’s 15 L) and deliver significantly more oxygen. What I’ve noticed is some of these patients come in at 50 or 60 percent on the pulse oximeter and you get some up into the high 80s, maybe even 90, with this approach. Then you can take a portable chest X-ray, get your labs drawn, and then turn them over and frequently they come up to 90 percent or higher.
The first paper on awake proning in the emergency department just published in Academic Emergency Medicine.1 Looking at a convenience sample of 50 patients from Lincoln Hospital in the South Bronx, it helped three-quarters patients avoid the need for intubation in the first 24 hours, and two-thirds avoid intubation throughout their hospitalization.
This study and the value of patient positioning maneuvers have now been widely discussed in blog posts and podcasts by Salim Rezaie, MD, FACEP (@srrezaie); Scott Weingart, MD (@emcrit), Josh Farkas, MD (@Pulmcrit), and others. Positioning maneuvers include proning, but also turning patients on their right and left sides and having them sit upright in a chair. Suzanne Bentley, MD, MPH, FACEP, at the Icahn School of Medicine at Mount Sinai in New York City, created a series of proning and positioning maneuvers for COVID-19 patients that is being used at Elmhurst Hospital and other public hospitals in New York City.
These maneuvers are not difficult in skinny patients. Obese patients crunch their lower lungs sitting upright in a stretcher and they often can’t tolerate proning at all. Since two-thirds of America qualifies as obese, that’s a real problem. To help patients tolerate proning, I tried a pregnancy massage mattress that I found online, which made it much more comfortable for patients to prone. It allowed obese patients who otherwise couldn’t to tolerate proning. I subsequently started a charity with my brothers, www.prone2help.org, to help get these mattresses to health care workers who need them. In the first three weeks, we sent more than 250 cushions to 125 hospitals in 30 states. We are now shipping a new design that has better access for oxygen devices. Clinicians can go to web site and request a cushion; it is sent out at no charge.