Q&A: Critical care and the COVID-19 pandemic
The COVID-19 pandemic has hit the United States hard, with the number of cases topping those seen in any other country, according to WHO. As the novel disease rapidly spreads, physicians, especially those caring for critically ill patients, face unique challenges and harbor questions about the future.
In an interview with Healio Pulmonology, Abhijit Duggal, MD, director of critical care research in the medical intensive care unit and associate program director of critical care fellowship at the Cleveland Clinic, and assistant professor of medicine at the Lerner School of Medicine of Case Western Reserve University, offered insight into how his institution is managing patients with COVID-19 and discussed his major concerns as the pandemic unfolds. – by Melissa Foster
What are your overall thoughts at the moment?
Duggal: Whenever we have a health threat of this magnitude, it’s concerning. Currently, there are two aspects of which we have to be particularly mindful. First, we have to provide appropriate, early care for sick people who are coming in with serious viral pneumonia. Second, we must do so while being aware of how this situation is going to unfold. We need to be mindful of the overall public health impact and predict the timing of the surge so that we can truly evaluate our needs and requirements.
In the critical care community, we’re definitely in the middle of this because we manage the sickest of the sick patients. Unfortunately, these treatments are resource-intensive, and we must be careful that we do not escalate care prematurely so we can conserve resources.
What are you seeing at your institution?
Duggal: In these situations, it is imperative that things are done in a protocolized way. We need to make sure that testing, management and treatment for these patients are consistent among health care providers and across specialties.
At Cleveland Clinic, we have prioritized testing patients based on recommendations from the CDC and being very careful about identifying and isolating people who are high risk, such as those who have been tested but have not been shown to be positive for the virus yet. Then, if someone is positive for COVID-19, we are implementing the appropriate isolation practices, as outlined by the CDC.
In terms of management of patients, our experience is similar to what has been reported globally. Most patients are not developing severe disease and have been isolated and have recovered at home. However, we are also seeing patients in the ICU who are developing significant acute hypoxemic respiratory failure associated with viral pneumonia that has necessitated early use of mechanical ventilation and supportive care. Our experience is still somewhat limited at this point, but we are seeing that vigilant, supportive care in the ICU can stabilize these patients reasonably quickly. Also, the experience from other countries, including China and Italy, has prepared us to anticipate potential deterioration in these patients and intervene accordingly. Discussions with our international colleagues, and preliminary experience from United States, has shown that many of these patients will be placed on mechanical ventilation. These patients require lung protective ventilation and high positive end-expiratory pressure. This allows for the recruitment of the lung parenchyma. Patients respond to this intervention fairly quickly, so we developed management protocols to implement standardized care for these patients.
Have you seen many of these patients?
Duggal: In Ohio, our surge is somewhat delayed compared with Washington and New York because we started testing patients a little later. However, we have definitely seen an uptick in diagnoses and are seeing an increase in the number of patients being admitted with severe disease requiring ICU care, mechanical ventilation and other supportive care.
What are your major concerns?
Duggal: The big concern — and this is true for any kind of viral pandemic situation — is that we really don’t know what the peak of this disease process is going to be. Is it going to last for several weeks or will it be more prolonged? Usually, whenever you’re in a pandemic situation, we look at our experience from previous viral outbreaks and pandemics. What we know is that the disease could peak for a short time and then stabilize over a couple of weeks or months or it could be prolonged, which is what we saw in 2009 with the H1N1 pandemic. During that pandemic, there was a first peak that lasted 4 to 6 months, followed by a lull and then a second peak. Therefore, we really need to be ready for any kind of eventuality and be prepared.
Another concern is that we’re in a situation in which we’re going to get a lot of patients very quickly and what are we going to do when that happens. In general, we have to work at a local level with our hospital leadership holding regular, multidisciplinary planning meetings to ensure that we are able to meet the critical needs we have. We must also collaborate with public health officials at the local, state and national and federal levels to communicate our needs and determine our ability to meet those needs when the time arises. Fortunately, at the Cleveland Clinic, our leadership is ready for this and they are looking at our options. We have a mechanism in place where we have the capacity to add up to a thousand beds within 72 hours if need be.
For me, the other big factor in this situation is to recognize where our resources are strained. Our experience from previous pandemics has taught us that we need a multidisciplinary approach among treating clinicians, hospitals, leadership and policymakers at both the local and national level. We will need the key stakeholders to assess our needs and implement the proposed plans.
Finally, we must look at all eventualities. At our institution, we do a lot of simulation and mock drills to ensure that our health care workers are ready for any type of need if a situation does arise in which we need to achieve surge capacity.
What is important for clinicians to know at this time?
Duggal: We need to protect patients who have not yet been exposed and treat the ones who have while protecting the health care workers from being exposed to this infection. We must be mindful of that so we can reduce the risk for nosocomial outbreaks of this virus. Therefore, having a very thorough institutional protocol regarding isolation of at-risk patients and those who have confirmed COVID-19 infections in place as well as following recommendations from health policy experts, including the CDC, are critical.
Second, every health care worker needs to be well versed in using personal protective equipment (PPE) before potential exposure to any of these patients. At Cleveland Clinic, we have developed extensive drills and simulations to ensure that all our health care workers understand the importance of appropriate use of PPE for both their own safety and the safety of their patients. It’s worth noting that the recommendations for their use varies based on the situation. For example, the need for PPE for a clinician caring for patients in the clinic is different than a clinician who is working in the ICU with invasive procedures. Clinicians should be aware that they require airborne protections, including N95 respirators, face masks and eye shields, for any type of aerosol-generating procedures, such as intubation, mechanical ventilation, bronchoscopy or nebulization of medications.
Third, social distancing is critical. We need to make sure that we isolate patients with suspected or confirmed infection so that other patients are not being exposed to the virus.
Finally, as we learn more about this virus, most of the critically ill patients with COVID-19 are presenting with acute hypoxemic respiratory failure and require aggressive supportive care. However, about one-quarter of these patients are also developing cardiomyopathy that is thought to be a viral cardiomyopathy secondary to this infection. This is happening 24 to 48 hours after acute presentation with respiratory failure and clinicians should be mindful of this when caring for patients.
In terms of specific therapies, there is a lot of guidance emerging regarding experimental treatments as well as treatments that have been used in other countries. There are also ongoing discussions about the right potential medication that can be used for these patients. Currently, chloroquine and lopinavir/ritonavir are being investigated for patients with COVID-19. Remdesivir (Gilead Sciences), which has been studied for other viral illnesses, is also being trialed at a number of institutions in the United States.
Another integral component of patient care during this pandemic is comanagement with infectious disease specialists. This collaboration is incredibly important as new information related to the care of these patient is rapidly emerging.
Do you have anything else to add?
Duggal: This encompasses most of what we know about the disease at this point. COVID-19 is novel and is acutely developing, and as we move forward, we will get more information about the clinical trajectory for these patients. Right now, though, this is what we know based on what we’re seeing and what’s being reported. This is a fluid situation, so we’ll have to stay vigilant.
Disclosure: Duggal reports no relevant financial disclosures.