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Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Pr Nicolas PESCHANSKI ECCC – Dec. 12th
COVID-19
Do’s & Dont’s in the
Prehospital
Emergency Setting
Associate Professor of Emergency Medicine
Emergency Physician Consultant
University Hospital – Rennes
Rennes-1 University School of Medicine
Steering Committee - French Society of Emergency Medicine
International Section - American College of Emergency Medicine
Web Community Section - European Society for Emergency Medicine
Steering Committee - Emergency Medicine Cardiac Research
Education Group
20 year of Emergency Medicine Practice
Pr Nicolas
PESCHANSKI
France - Brittany
University Hospital Rennes – Emergency Dept. &
SAMU
Emergency attendees in 2018: 115.000 (69.000 adults)
COVID-19 patient treated in ICU/CCU first wave: 172 (max. 54)
COVID-19 results in first wave 2020’ Mars to August: 574 pts
COVID-19 experience of ED team: > 10.000 tests / > 600 pts />
100 EMS
COVID-19 mortality rate: from 11% (wards) to 34% (ICU)
Actual 2nd wave situation Nov. 6th: 104 pts hospitalized (23 ICU, 9
University Hospital Rennes – COVID-19
Vygon SA©
Fisher & Paykel Healthcare
Pre-hospital O2 Support
@ the Beginning of the
COVID-19 Pandemic
01.
WH
O
https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf
Oxygenation Objective
SpO2 ≥ 93%
Clinical managemen of e e e ac e e pi a o infec ion (SARI) hen COVID-19 di ea e i pec ed: In e im g idance V 1.2.
6. Managemen of e e e COVID-19: o gen he ap and moni o ing
Gi e s pplemental o gen therap immediatel to patients ith SARI and respirator distress, h po aemia or shock
and target > 94%.
Remarks for ad lts: Ad h e e ge c g ( b c ed ab e b ea h g, e e e e a d e , ce a
c a , h c , c a c ) h d ece e a a a age e a d ge he a d g e c a a ge
S O2 94%. I a e ge he a a 5 L/ a d a e f a e each a ge S O2 93% d g e c a ; e
face a h e e bag (a 10 15 L/ ) f a e c ca c d . O ce a e ab e, he a ge > 90% S O2
- eg a ad a d 92 95% eg a a e (16, 25).
Remarks for children: Ch d e h e e ge c g ( b c ed ab e b ea h g, e e e e a d e , ce a
c a , h c , c a c ) h d ece e a a a age e a d ge he a d g e c a a ge
S O2 94%; he e, he a ge S O2 90% (25). U e f a a g a a ca a efe ed g ch d e ,
a a be be e e a ed.
Remark 3: A a ea he e a e h SARI a e ca ed f h d be e ed h e e e , f c g ge
e a d d ab e, g e- e, ge -de e g e face ( a a ca a, a a g , e face a a d a
h e e bag). See A e d f de a f e ce .
Closel monitor patients ith COVID-19 for signs of clinical deterioration, s ch as rapidl progressi e
respirator fail re and sepsis and respond immediatel ith s pporti e care inter entions.
WH
O
https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf
Clinical managemen of e e e ac e e pi a o infec ion (SARI) hen COVID-19 di ea e i pec ed: In e im g idance V 1.2.
8. Managemen of c i ical COVID-19: ac e e pi a o di e nd ome (ARDS)
Recogni e se ere h po emic respirator fail re hen a patient ith respirator distress is failing standard o gen
therap and prepare to pro ide ad anced o gen/ entilator s pport.
Remarks: Pa e a c e ha e c ea ed f b ea h g h e a e e he ge de e ed a a face
a h e e bag (f a e f 10 15 L/ , h ch ca he f e ed a a bag f a ;
F O2 0.60 0.95). H e c e a fa e ARDS c e f a a e a - e f a ch
h a d a e e echa ca e a (5).
Endotracheal int bation sho ld be performed b a trained and e perienced pro ider sing airborne preca tions.
Remarks: Pa e h ARDS, e ec a g ch d e h e h a e be e eg a , a de a a e c d g
ba . P e- ge a e h 100% F O2 f 5 e , a a face a h e e bag, bag- a e a , HFNO NIV.
Ra d e e ce ba a a e af e a a a a e e ha de f e g f d ff c ba (28, 29,.
30).
The f g ec e da e a echa ca e a ed ad a d aed a c a e h ARDS (5, 31).
If O2 needs > 5 L/min
For SpO2 > 94%
If O2 needs > 5 L/min
For SpO2 > 94%
Viral Particles Spreading
Leung CCH, et al. J Hosp Infect 2019
NPPV
Nebulizer
Low Flow O2 Mask
High Flow O2 Mask (Venturi)
Nasal Canula O2
HFNO
NRM
0 100 cm
Pre-hospital O2 Support
in Amidst of the COVID-
19
A Paradigme Shift
02.
Italy…
Covid-19 Does Not Lead to a “Typical” Acute
Respiratory Distress Syndrome AJRCCM 2020
COVID-19 pneumonia: different respiratory
treatments for different phenotypes?
Intensive Care Med 2020
COVID- 19 Pneumonia =
"Atypical" ARDS ?
Same virus, but two phenotypes?
Same virus, but two phenotypes?
L- Type
• Low elastance. The nearly normal compliance indi-
cates that the amount of gas in the lung is nearly
normal.
• Low ventilation-to-perfusion (VA/Q) ratio. Since
the gas volume is nearly normal, hypoxemia may
be best explained by the loss of regulation of
perfusion and by loss of hypoxic vasoconstriction.
Accordingly, at this stage, the pulmonary artery
pressure should be near normal.
• Low lung weight. Only ground-glass densities are
pre- sent on CT scan, primarily located subpleurally
and along the lung fissures. Consequently, lung
weight is only moderately increased.
• Low lung recruitability. The amount of non-
aerated ue is very low; consequently, the
recruitability is low.
H - Type
• High elastance. The decrease in gas volume due to
increased edema accounts for the increased lung
elastance.
• High right-to-left shunt. This is due to the fraction
of cardiac output perfusing the non-aerated tissue
which develops in the dependent lung regions due
to the increased edema and superimposed
pressure.
ee
• High lung weight. Quantitative analysis of the CT
scan shows a remarkable increase in lung weight (>
1.5 kg), on the order of magnitude of severe ARDS
e
• High lung recruitability. The increased amount of
non-aerated tissue is associated, as in severe ARDS,
with increased recruitability
Same virus, but two phenotypes?
L- Type
• Low elastance. The nearly normal compliance indi-
cates that the amount of gas in the lung is nearly
normal.
• Low ventilation-to-perfusion (VA/Q) ratio. Since
the gas volume is nearly normal, hypoxemia may
be best explained by the loss of regulation of
perfusion and by loss of hypoxic vasoconstriction.
Accordingly, at this stage, the pulmonary artery
pressure should be near normal.
• Low lung weight. Only ground-glass densities are
pre- sent on CT scan, primarily located subpleurally
and along the lung fissures. Consequently, lung
weight is only moderately increased.
• Low lung recruitability. The amount of non-
aerated ue is very low; consequently, the
recruitability is low.
H - Type
• High elastance. The decrease in gas volume due to
increased edema accounts for the increased lung
elastance.
• High right-to-left shunt. This is due to the fraction
of cardiac output perfusing the non-aerated tissue
which develops in the dependent lung regions due
to the increased edema and superimposed
pressure.
ee
• High lung weight. Quantitative analysis of the CT
scan shows a remarkable increase in lung weight (>
1.5 kg), on the order of magnitude of severe ARDS
e
• High lung recruitability. The increased amount of
non-aerated tissue is associated, as in severe ARDS,
with increased recruitability
85%15%
Same Spectrum of a Pathophysiological Evolution
Linked to Time and/or Severity?
15%
85%
Ziehr DZ, et al. AJRCCM 2020 (PMID: 32348678)
L
H
JAMA 2012;307(23)
”Typical” ARDS?
The Berlin Criteria
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Let me guess?
Let me guess?
Not in the Prehospital Setting !
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Sun et al. Ann. Intensive Care (2020) 10:33
Paradigm Shift
COVID- 19 Pneumonia
Early intubation as soon as O2 > 6l/min
Because NPPV/NIV don't work!
High risk of aerosolization with NIV/NPPV and HFNC
Early Rules
HFNC or Non-invasive O2 supports possible
Prone positioning
Upgrade to
Lesson of the 1st Wave
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Pre-hospital O2 Support
Guidelines and Beyond
03.
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
LFNC
LFNC + Non-rebreather Mask
O2 Support
Is There a Place for
High-Flow Nasal Canula
Humifified Oxygenation
in COVID-19 Pneumonia?
04.
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
HFNC
HFNC
HFNC ☞ Rebreather Mask
(Helmet)
2. Rebreather mask
(COPD)
5. Intubation
Expiratory valve
HEPA-Filter
(Pleated
Membrane)
HME-Filter
HFNC
O2 Support
Is There a Place for
Non-invasive Positive Pressure
Ventilation
in COVID-19 Pneumonia?
05.
NPPV (Bi-Level)*
*only for COPD
(Helmet)
2. Rebreather mask
(COPD)
O2 Support
Is There a Place for
Boussignac-CPAP
in COVID-19
Pneumonia?
06.
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
(COPD)
2. Rebreather mask
3. Boussignac CPAP
5.
Pre-hospital O2 Support
in COVID-19 Pneumonia
Mechanical Vent
Could Be Needed!
07.
Mechanical Ventilation
NPPV (Helmet)
(Helmet)
2. Rebreather mask 5.
Pre-hospital O2 Support
in COVID-19 Pneumonia
Less Could Be
More!
07.
ProposedO2-Support
inPre-hospitalSetting
What About Airborne Spreading with 02-Support?
1. CPAP @ 20 cmH2O with facial mask induce
negligible air dispersion.
2. “Thus, we can state that CPAP via an oronasal
mask and NIV via a helmet equipped with an
inflatable neck cushion are the ventilatory
support methods that allow the minimum
room air contamination.”
Viral Particles Spreading
Adapted from Leung CCH, et al. J Hosp Infect 2019
NPPV
Nebulizer
Low Flow O2 Mask
High Flow O2 Mask (Venturi)
Nasal Canula O2
HFNO
NRM
0 100 cm
Boussignac CPAP
• Max FiO2: 100%
• Dispersion 30 cm
• Apply Filter
Proposed O2-Support Algorithm
CPAP
CPAP/Helmet
Thank you
Questions?
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020

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Dos and donts in the emergency pre hospital setting covid-19 eccc 2020

  • 2. Pr Nicolas PESCHANSKI ECCC – Dec. 12th COVID-19 Do’s & Dont’s in the Prehospital Emergency Setting
  • 3. Associate Professor of Emergency Medicine Emergency Physician Consultant University Hospital – Rennes Rennes-1 University School of Medicine Steering Committee - French Society of Emergency Medicine International Section - American College of Emergency Medicine Web Community Section - European Society for Emergency Medicine Steering Committee - Emergency Medicine Cardiac Research Education Group 20 year of Emergency Medicine Practice Pr Nicolas PESCHANSKI
  • 5. University Hospital Rennes – Emergency Dept. & SAMU
  • 6. Emergency attendees in 2018: 115.000 (69.000 adults) COVID-19 patient treated in ICU/CCU first wave: 172 (max. 54) COVID-19 results in first wave 2020’ Mars to August: 574 pts COVID-19 experience of ED team: > 10.000 tests / > 600 pts /> 100 EMS COVID-19 mortality rate: from 11% (wards) to 34% (ICU) Actual 2nd wave situation Nov. 6th: 104 pts hospitalized (23 ICU, 9 University Hospital Rennes – COVID-19
  • 7. Vygon SA© Fisher & Paykel Healthcare
  • 8. Pre-hospital O2 Support @ the Beginning of the COVID-19 Pandemic 01.
  • 9. WH O https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf Oxygenation Objective SpO2 ≥ 93% Clinical managemen of e e e ac e e pi a o infec ion (SARI) hen COVID-19 di ea e i pec ed: In e im g idance V 1.2. 6. Managemen of e e e COVID-19: o gen he ap and moni o ing Gi e s pplemental o gen therap immediatel to patients ith SARI and respirator distress, h po aemia or shock and target > 94%. Remarks for ad lts: Ad h e e ge c g ( b c ed ab e b ea h g, e e e e a d e , ce a c a , h c , c a c ) h d ece e a a a age e a d ge he a d g e c a a ge S O2 94%. I a e ge he a a 5 L/ a d a e f a e each a ge S O2 93% d g e c a ; e face a h e e bag (a 10 15 L/ ) f a e c ca c d . O ce a e ab e, he a ge > 90% S O2 - eg a ad a d 92 95% eg a a e (16, 25). Remarks for children: Ch d e h e e ge c g ( b c ed ab e b ea h g, e e e e a d e , ce a c a , h c , c a c ) h d ece e a a a age e a d ge he a d g e c a a ge S O2 94%; he e, he a ge S O2 90% (25). U e f a a g a a ca a efe ed g ch d e , a a be be e e a ed. Remark 3: A a ea he e a e h SARI a e ca ed f h d be e ed h e e e , f c g ge e a d d ab e, g e- e, ge -de e g e face ( a a ca a, a a g , e face a a d a h e e bag). See A e d f de a f e ce . Closel monitor patients ith COVID-19 for signs of clinical deterioration, s ch as rapidl progressi e respirator fail re and sepsis and respond immediatel ith s pporti e care inter entions.
  • 10. WH O https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf Clinical managemen of e e e ac e e pi a o infec ion (SARI) hen COVID-19 di ea e i pec ed: In e im g idance V 1.2. 8. Managemen of c i ical COVID-19: ac e e pi a o di e nd ome (ARDS) Recogni e se ere h po emic respirator fail re hen a patient ith respirator distress is failing standard o gen therap and prepare to pro ide ad anced o gen/ entilator s pport. Remarks: Pa e a c e ha e c ea ed f b ea h g h e a e e he ge de e ed a a face a h e e bag (f a e f 10 15 L/ , h ch ca he f e ed a a bag f a ; F O2 0.60 0.95). H e c e a fa e ARDS c e f a a e a - e f a ch h a d a e e echa ca e a (5). Endotracheal int bation sho ld be performed b a trained and e perienced pro ider sing airborne preca tions. Remarks: Pa e h ARDS, e ec a g ch d e h e h a e be e eg a , a de a a e c d g ba . P e- ge a e h 100% F O2 f 5 e , a a face a h e e bag, bag- a e a , HFNO NIV. Ra d e e ce ba a a e af e a a a a e e ha de f e g f d ff c ba (28, 29,. 30). The f g ec e da e a echa ca e a ed ad a d aed a c a e h ARDS (5, 31). If O2 needs > 5 L/min For SpO2 > 94%
  • 11. If O2 needs > 5 L/min For SpO2 > 94%
  • 12. Viral Particles Spreading Leung CCH, et al. J Hosp Infect 2019 NPPV Nebulizer Low Flow O2 Mask High Flow O2 Mask (Venturi) Nasal Canula O2 HFNO NRM 0 100 cm
  • 13. Pre-hospital O2 Support in Amidst of the COVID- 19 A Paradigme Shift 02.
  • 15. Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome AJRCCM 2020 COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med 2020
  • 16. COVID- 19 Pneumonia = "Atypical" ARDS ? Same virus, but two phenotypes?
  • 17. Same virus, but two phenotypes? L- Type • Low elastance. The nearly normal compliance indi- cates that the amount of gas in the lung is nearly normal. • Low ventilation-to-perfusion (VA/Q) ratio. Since the gas volume is nearly normal, hypoxemia may be best explained by the loss of regulation of perfusion and by loss of hypoxic vasoconstriction. Accordingly, at this stage, the pulmonary artery pressure should be near normal. • Low lung weight. Only ground-glass densities are pre- sent on CT scan, primarily located subpleurally and along the lung fissures. Consequently, lung weight is only moderately increased. • Low lung recruitability. The amount of non- aerated ue is very low; consequently, the recruitability is low. H - Type • High elastance. The decrease in gas volume due to increased edema accounts for the increased lung elastance. • High right-to-left shunt. This is due to the fraction of cardiac output perfusing the non-aerated tissue which develops in the dependent lung regions due to the increased edema and superimposed pressure. ee • High lung weight. Quantitative analysis of the CT scan shows a remarkable increase in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS e • High lung recruitability. The increased amount of non-aerated tissue is associated, as in severe ARDS, with increased recruitability
  • 18. Same virus, but two phenotypes? L- Type • Low elastance. The nearly normal compliance indi- cates that the amount of gas in the lung is nearly normal. • Low ventilation-to-perfusion (VA/Q) ratio. Since the gas volume is nearly normal, hypoxemia may be best explained by the loss of regulation of perfusion and by loss of hypoxic vasoconstriction. Accordingly, at this stage, the pulmonary artery pressure should be near normal. • Low lung weight. Only ground-glass densities are pre- sent on CT scan, primarily located subpleurally and along the lung fissures. Consequently, lung weight is only moderately increased. • Low lung recruitability. The amount of non- aerated ue is very low; consequently, the recruitability is low. H - Type • High elastance. The decrease in gas volume due to increased edema accounts for the increased lung elastance. • High right-to-left shunt. This is due to the fraction of cardiac output perfusing the non-aerated tissue which develops in the dependent lung regions due to the increased edema and superimposed pressure. ee • High lung weight. Quantitative analysis of the CT scan shows a remarkable increase in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS e • High lung recruitability. The increased amount of non-aerated tissue is associated, as in severe ARDS, with increased recruitability 85%15%
  • 19. Same Spectrum of a Pathophysiological Evolution Linked to Time and/or Severity? 15% 85% Ziehr DZ, et al. AJRCCM 2020 (PMID: 32348678)
  • 20. L H
  • 24. Let me guess? Not in the Prehospital Setting !
  • 26. Sun et al. Ann. Intensive Care (2020) 10:33
  • 27. Paradigm Shift COVID- 19 Pneumonia Early intubation as soon as O2 > 6l/min Because NPPV/NIV don't work! High risk of aerosolization with NIV/NPPV and HFNC Early Rules HFNC or Non-invasive O2 supports possible Prone positioning Upgrade to Lesson of the 1st Wave
  • 31. LFNC
  • 33. O2 Support Is There a Place for High-Flow Nasal Canula Humifified Oxygenation in COVID-19 Pneumonia? 04.
  • 35. HFNC
  • 36. HFNC
  • 40. O2 Support Is There a Place for Non-invasive Positive Pressure Ventilation in COVID-19 Pneumonia? 05.
  • 43. O2 Support Is There a Place for Boussignac-CPAP in COVID-19 Pneumonia? 06.
  • 48. (COPD) 2. Rebreather mask 3. Boussignac CPAP 5.
  • 49. Pre-hospital O2 Support in COVID-19 Pneumonia Mechanical Vent Could Be Needed! 07.
  • 53. Pre-hospital O2 Support in COVID-19 Pneumonia Less Could Be More! 07.
  • 55. What About Airborne Spreading with 02-Support?
  • 56. 1. CPAP @ 20 cmH2O with facial mask induce negligible air dispersion. 2. “Thus, we can state that CPAP via an oronasal mask and NIV via a helmet equipped with an inflatable neck cushion are the ventilatory support methods that allow the minimum room air contamination.”
  • 57. Viral Particles Spreading Adapted from Leung CCH, et al. J Hosp Infect 2019 NPPV Nebulizer Low Flow O2 Mask High Flow O2 Mask (Venturi) Nasal Canula O2 HFNO NRM 0 100 cm Boussignac CPAP
  • 58. • Max FiO2: 100% • Dispersion 30 cm • Apply Filter Proposed O2-Support Algorithm CPAP CPAP/Helmet

Editor's Notes

  1. J’explique ici pourquoi initialement le choix a été fait de ne pas utiliser les supports d’oxygénation non-invasifs
  2. HFNC !!
  3. J’explique ici pourquoi initialement le choix a été fait de ne pas utiliser les supports d’oxygénation non-invasifs