Is COVID-19 ARDS? L & H Phenotypes Explained!
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- Опубліковано 4 чер 2024
- In this lesson we have a discussion about whether COVID-19 is truly ARDS. A paper by one of the world leading experts on ARDS addresses this question and believes it is not in most cases. They developed a theory of 2 distinct phenotypes to COVID-19.
I start off talking about these phenotypes; type L and type H. Type L is classified with "low" things such as low elastane, low V/Q ratio, low lung weight, and low recruit ability of the lungs. The L type does not appear like typical ARDS. Then there is type H distinguished with "high" things such as high elastane, high right to left shunt, high lung weight, and high recruit ability. I also cover their belief of the transition from one type to the other and why that might happen.
Next we cover the respiratory treatment proposed by this paper in response to the different needs of the different phenotypes. Finally I cover some potentially issues that have been raised regarding this theory.
I hope that by the end of this you guys have a bette understanding of what these different phenotypes are, how they are different, and how our management of these patients might differ from one another.
0:00 Intro
3:50 Physiological Findings
8:31 Respiratory Treatment
10:48 Potential Issues
12:20 Conclusion
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Thank you so much for all your COVID videos. I’m learning so much everyday at our PCU Covid floor, and this makes everything make sense.
Awesome! Really happy to hear you've found these videos helpful!
Very nice video, you make it easier to understand! Thanks from Brazil 💗😃
Ahh how cool! So glad that you enjoyed the video and hello all the way in Brazil! Hope you are doing well!
Hey sir...I m ur new subscriber...really found this video helpful as i have to work with this for my homework....
U have explained phenotype clearly please
1.head towards genotype of corona virus
2.genetic cycle of coronavirus
3. Also how to fight corona (along with genetic description)
It will be really beneficial...
Thank you...🥰
I am a Pulm. Icu MD
Appreciate your work.
Love your videos.
Thank you.
Very cool! Glad you enjoy them and thanks so much for taking the time to leave a comment!
Mutant Chimp,
Have ANY of your patients died from lung failure?
Nice updated presentation on various aspects of COVID-90
Thank you!
Thanks, ICU Advantage. Great video!
Alll-
Approx 3 minutes in, Berlin criteria is discussed, then a statement is made about the typical high pulmonary compliance in COVID19 so it doesn't correlate to Berlin criteria's definitions of ARDS.
Did you mean to say ARDSnet definition of ARDS?
When using Berlin criteria to diagnose ARDS & it's severity level, isn't pulmonary compliance DISREGARDED, & ARDS determined by pao2/fio2; of a patient on mech vent & above certain peep & fio2?
Thanks Gina. I had to go back and re-read the article. You are correct about the Berlin criteria. I misspoke, as the point that he was making was that by all accounts the P:F ratios would fall in the the classic ARDS definition according to the Berlin criteria, but the presentation of normal compliance, was not typically seen in most cases of ARDS. While they initially had 4 ancillary variables included with the Berlin criteria (compliance being one), they did choose to not include those as they had no predictive value for mortality.
Hi! I don't really get that a low V/Q ratio (low ventilation, normal to high perfusion I would think) is marked as 'decreased perfusion'?
I realised that and that is why I am here in the comment section searching for someone who noticed that too
I think it is a small mistake actually he means low ventilation tho
He also said that in L type we have low lung recruit ability ie non air aerated lung tissue
Any chance of a future video covering CVVHD?
Love your content btw. Helping me out a lot in growing as an ICU nurse. Currently studying for my CCRN as well.
Yes, I really do plan to get to it eventually! 😊 And I'm so glad these videos have been helpful for you and best of luck on your CCRN. Would love an update once you get it!
Loved It!
Thank you!
So interesting to go back to these videos and think about all that we are learning and have yet to learn about COVID. These patients are so challenging but we will get through this as stronger, more knowledgeable nurses.. It’s been so bad in Phoenix these last couple of months. Hope all of you guys are staying safe out there and getting vaccinated 💉
It is very interesting. I go back and watch some of these older videos I've done and find it fascinating at how quick we were trying to understand so much that was new. I do 100% agree that in the end we will be stronger, despite how tough things are right now. I am also in the Phoenix area and can relate 100%! It seems like it is starting to go in the right direction again, thank God. Thanks for all that you do and make sure you take care and be safe!
Have the author's made changes to this article? I ask because I'm not aware of any patients dying of actual lung failure (pH, CO2 or PO2) no anoxic injuries yet either. But, I only work at one hospital & haven't discussed their patients main causes of death with other respiratory therapists.
Once we pass low flow O2, PRM, HFNC, NIV/CPAP.
Once intubated every COVID19 patient is put on 2 protocols & sometimes Flolan (we don't have anything else)
#1) ARDSnet guided lung protection protocol vent settings (vt 4-6 ml/kg IBW, pH, PaO2, plateau pressure) AND
#2) Early proning using 2013 PAO2/FIO2 guidelines for early proning
We've terminally extubated for kidney failure, strokes, possibly hemodynamics but I don't think so (its hard to determine if remdesivir or the low BP is causing renal failure....I think it's remdesivir), & a terminal extubation secondary to an ethics committee decision. I can see bleeding & subsequent hypoxia
eventually being a reason (so far our bleeders haven't died), can also see TRALI being possible from the plasma...no so far, but even then, would that be primary lung failure or TRALI (definitely not COVID19 despite what death certifiers say) BUT NO deaths from respiratory or blood pressure, no CPR or cardiopulmonary arrests.
Note: I'm in Midwest & despite dealing with COVID19 from the beginning, this is our first WTF NO ROOM, NOT ENOUGH NURSES & RTs situation we've been in since it started; I may start to see death from primary lung failure.
I haven't seen anything new from the authors on this topic, but I haven't spent as much time researching as I had previously. I did also want to present this theory at the time as it was something that was being talked a lot about. Some still follow this line of thinking. I personally don't think these different phenotypes exist as presented in this paper.
As for mortality, while certainly some have have such profound hypoxia that led ultimately to cardiac arrest and death, the large majority of patients ultimately succumb to the systemic effects of hypoxia, cytokine storm, and microvascular clotting. MODS is the main killer.
Long term vent cases also battle with massively fibrotic lung tissue and often times bleeding and multiple chest tubes, which ultimately end up pushing up mortality.
I do think early on, there was a lot more early intervention with intubation and ventilatory support that exacerbated some of the direct lung injury and mortality we saw. We have come a long way in our management. Better non-invasive support strategies, coupled with early steroids, anticoagulation, and others have certainly improved our outcomes.
We are seeing an increase in cases here again, but so far, nothing like the huge spike we saw in June/July so it will be interesting to see if the same "results" we are seeing now will carry forward then. I'm hopeful.
That said, make sure and keep yourself safe both physically and mentally.