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COVID-19: Key Learnings from the ICU
James Walter, MD, assistant professor in the Division of Pulmonary and Critical Care and Medical Director of the Lung Rescue Program, shares lessons his team has learned while treating some of the most critically ill patients suffering from Coronavirus Disease 2019 (COVID-19). Walter discusses how the team is using evidence-based therapies such as prone positioning, early mechanical ventilation and extracorporeal membrane oxygenation (ECMO) to improve outcomes for patients with COVID-19 and protect staff from exposure.
Featured Speaker:
James Walter, MD
James Walter, MD is a Pulmonary and Critical Care physician and Medical Director of the Northwestern Lung Rescue Program.Dr. Walter attended Princeton University followed by medical school at the University of Chicago Pritzker School of Medicine. He completed his Internal Medicine residency at the University of Michigan followed by fellowship training in Pulmonary and Critical Care Medicine at Northwestern Memorial Hospital. Dr. Walter’s clinical interests are in the care of adult patients with acute respiratory failure and shock including the use of extracorporeal membrane oxygenation. His research is focused on the use of next generating sequencing techniques to improve the diagnosis and treatment of patients with severe pneumonia. Dr. Walter has a strong interest in medical education and is involved in teaching and curricular development for both undergraduate and graduate medical education. Transcription:
COVID-19: Key Learnings from the ICU
Melanie Cole: This is the Northwestern Medicine Podcast on COVID-19 dated March 31st, 2020 Welcome. This is Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole. Today we're discussing treating patients with COVID-19. Joining me is Dr. James Walter. He's an Assistant Professor in the division of Pulmonary and Critical Care and the Medical Director of the Lung Rescue Program at Northwestern Medicine. Dr. Walter, it's such a pleasure to have you here in this unprecedented time and I imagine you are just absolutely so busy. Please explain for the listeners first how the virus damages the lungs and how that leads to the need for critical care. Tell us what it's doing to our lungs.
Dr. Walter: Sure. Well, thanks for the opportunity to speak with you today. COVID-19 is a unique virus. It attaches to a specific receptor called the ACE 2 receptor, and that's how it gets access to the cells in our body. The cells in our lung have a very high percentage of these receptors. So that in part explains why we're seeing so much lung disease specifically pneumonia and a more severe form of lung injury called acute respiratory distress syndrome in patients who are infected with the Coronavirus. So we've seen a wide range of pathology and patients who are infected from asymptomatic patients, and the ones that we're really focusing on here in the hospital and specifically in the intensive care unit are patients with pneumonia and then acute respiratory distress syndrome, which results in severe hypoxemic respiratory failure.
Host: Well, thank you for that answer. What are some of the ways that Northwestern Memorial Hospitals, Pulmonary Critical Care and Thoracic Surgery is treating patients right now with COVID-19?
Dr. Walter: Thank you. Yeah, that's a great question. I think it starts with very early identification and having a low index of suspicion to think about Coronavirus infection. For patients who are starting to show signs of hypoxemia, our next step is really to think proactively about when patients need more definitive airway management and collaboration with our division and anesthesia and critical care, and thoracic surgery. We've been moving towards fairly early mechanical ventilation in these patients when they get to around five to six liters of nasal cannula. And that's both because we've seen inpatients around that level of support who can develop fairly progressive and rapid hypoxemic respiratory failure, and also to minimize risk of exposure to our staff so that airway management is done in a more controlled situation than a truly crash intubation. Now once patients get to our medical intensive care unit, we really focus on providing evidence based best practice that we would use for all our critically ill patients. So that includes being really thoughtful and looking thoroughly for evidence of coinfection in the mung, including viruses and other bacterial pneumonia is which may be contributing to the patient's decompensation.
And for patients who are starting to develop signs of acute respiratory distress syndrome. What we've really focused on is one, attention to low tidal volume ventilation, so six CCs per kg, ideal body weight with a plateau pressure less than. 30 and what we've noticed early on in a patient's course is that their lungs are actually much more compliant than we see with other causes of acute respiratory distress syndrome. So we're able to ventilate these patients earlier, early on with fairly high low distending pressures that give us reasonable tidal volumes, which is different than other forms of ARDS. And then the other things we focus on are what we do for other ICU patients. Work really closely with our nursing staff and our respiratory therapist to make sure we're on the lowest dose of sedation that's needed to start early and add on nutrition and to use prophylactic treatments for venous thromboembolism and to make sure that we're deescalating lines, and other things that we know are associated with really good outcomes for our critically ill patients.
Host: So Dr. Walter, you mentioned when you decide to initiate mechanical ventilator, you told us when that is, but what about other forms of intervention such as proning or what else are you doing for patients?
Dr. Walter: Sure. So I'm really thrilled to work here at Northwestern where I think we can offer some really cutting edge and evidence based therapies for patients with the most severe hypoxemia as a result of their Coronavirus infection. One thing that I'm particularly proud of is our efforts to provide prone positioning, which is a therapy for patients with severe hypoxemic respiratory failure where we actually turn them into the prone position. So they're facing the floor and we've actually, this has been over a year long quality improvement initiative in our medical intensive care unit where nurses or respiratory therapists and our physicians have really come together to develop evidence based protocols to do this in efficient, safe way for all of our patients. So this has been a really great opportunity to implement this evidence based practice specifically for patients with Coronavirus. I think we're really expert at doing it here. And we've developed protocols that mirror the protocols in Europe where this has been shown to improve survival for patients with ARDS.
So we've already implemented prone positioning in a large number of patients in our medical intensive care unit with Coronavirus and have done that quickly, effectively and with minimal interruptions in patient care and really trying to minimize exposure risk to our providers. And we also have the opportunity to provide extracorporeal membrane oxygenation support. We have very, a really high functioning multidisciplinary collaborative extracorporeal membrane oxygenation support team, which includes members of thoracic surgery, pulmonary critical care, perfusionists, respiratory therapists and physical therapists. So this has been something that's been ongoing for the past several years and it's a very unique time to think about using ECMO in patients with Coronavirus infection to date. We've had two patients on ECMO. We're very careful about who we select to place on ECMO, but I think we're really well positioned to provide that very advanced form of oxygenation support here at Northwestern because of how ingrained our protocols are in our multidisciplinary model of care between surgery and pulmonary critical care.
Host: That's encouraging and very advanced and thank you so much, Dr. Walter. What have been some of the lessons that you've learned along the way in how we're all treating this virus?
Dr. Walter: Yeah, that's a really good question. I think the things that we've learned are to a couple. The first is to be flexible. We learn more every day about the best way to identify and treat these patients and to minimize risk of exposure to clinicians and other staff who are involved in these patient's care. So I think really trying to keep an open mind and be malleable in terms of adapting our practice models. I've been thrilled to watch our entire division from both outside the hospital and the ones at the bedside come together. We've rapidly developed a set of guidelines to follow for care in the intensive care unit, trying to develop consensus among our divisions and our other colleagues in both within the department of medicine, and outside in thoracic surgery about the best way to care for these patients. And I think the continuing to think collaboratively with all the providers about what we're learning and what we can do better, has been a really important lesson. And just being adaptive to changes in patient volume and staffing. I think another really important lesson that we've learned is the just sheer number of anecdotes and information that is out there on social media.
And the peer review literature on potential therapies can be incredibly overwhelming both for clinicians on the ground and for patients and families to try to sift through which of these are best positioned to improve outcomes for our sickest patients. And what I've been, what I've noticed is that here in Northwest and we've really placed an emphasis on doing what we know works, which is really high quality evidence based best practice that we use for our critically ill patients. And then picking the most promising interventions and then studying those, implementing those in a randomized controlled trial. We've picked two, which is remdesivir and then a different medicine, which is an Aisle 6 antagonist that we can enroll patients in randomized controlled trials. So that both gives our patients an opportunity to receive these novel therapies, but also really importantly allows us to learn from the use of these drugs. We can quickly learn what works and what doesn't. And I think that's a really important lesson to not to try to really be thoughtful about these investigational therapies we're using and implementing them in a way that both benefits patients and benefits the scientific community at large.
Host: Well, it certainly does. And as you say, it's so important. That's a great point that you made about being malleable and adaptive because this is certainly something we've not seen before. So how are you safely helping patients get through their treatment without spreading the virus? And talk us through how you and your medical partners are taking precautions to protect yourselves and other healthcare providers while you're giving those treatments.
Dr. Walter: Sure. So we really closely adhere to the recommendations from our hospital leadership on best practice for donning and doffing personal protective equipment for minimizing risk of exposure to staff during aerosolized generating procedures like intubations and bronchoscopies. We cohort currently all of our both suspected infected patients and our confirmed Coronavirus infected patients in specifically designated units within our hospital so that we can have dedicated teams that become really expert at these best practices to minimize infections and minimize the risk of exposure to staff and other patients. So we every day are regrouping on what we know, what we're learning from all of our experience, about the best way to minimize exposure and thinking collaboratively about the making, ensuring we're following those recommendations
Host: As we wrap up, what else do physicians need to know about COVID-19 to manage their patients and when you feel it's really important that they refer to the experts at Northwestern Medicine?
Dr. Walter: Yeah, it's a really good question. I think in terms of, I'll answer the second one first about when to refer to us. You know, we really see ourselves as being well positioned to provide the most advanced life-sustaining treatments for patients specifically with acute respiratory distress syndrome and the potential cardiovascular complications of Coronavirus infection. And like I mentioned before, I think we're really expert at providing ventilation in the prone position, which is a evidence based therapy for ARDS and we're a really high performing center for extracorporeal membrane oxygenation. So for patients who are developing more severe hypoxemic respiratory failure, we really want our other hospitals to reach out to us to one get recommendations on ventilator management and other therapies. And then to think collaboratively with us about would those specific patients benefit from transfer here to implement prone positioning. And I think particularly to think about when to use ECMO for patients with the most severe hypoxemic respiratory failure, which is I think a very unique service that our center does very well.
Host: Do you have any final thoughts about COVID-19 you'd like to share, Dr. Walter?
Dr. Walter: Like you mentioned at the beginning, it's really an unprecedented time to be a patient, to be a patient's loved one, and to be a provider at an academic medical center. I think that the amount we're learning every day, the stress it puts on everyone, both in the healthcare system and outside, it's a lot to handle. And I think here at Northwestern we've taken a lot of comfort in working together, really trying to lean on the sense of community and teamwork that's been stressed every day in meetings and during bedside care, and to never lose sight of that. Our main focus here is to take the best care of all the patients that come through our hospital's doors. So we're really focused on that. And I get the privilege of working with a really wonderful group of providers, both physicians, respiratory therapists, nurses, perfusionists, really wonderful team. And I think that's what gets us through some really difficult times in the hospital.
Host: Well, the multidisciplinary team approach is so important at this time and really all the time. And thank you so much, Dr. Walter for coming on and updating us about what you're doing to treat patients with COVID-19 at Northwestern Medicine. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. To refer your patient or for more information on COVID-19 please visit our website at nm.org to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.
COVID-19: Key Learnings from the ICU
Melanie Cole: This is the Northwestern Medicine Podcast on COVID-19 dated March 31st, 2020 Welcome. This is Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole. Today we're discussing treating patients with COVID-19. Joining me is Dr. James Walter. He's an Assistant Professor in the division of Pulmonary and Critical Care and the Medical Director of the Lung Rescue Program at Northwestern Medicine. Dr. Walter, it's such a pleasure to have you here in this unprecedented time and I imagine you are just absolutely so busy. Please explain for the listeners first how the virus damages the lungs and how that leads to the need for critical care. Tell us what it's doing to our lungs.
Dr. Walter: Sure. Well, thanks for the opportunity to speak with you today. COVID-19 is a unique virus. It attaches to a specific receptor called the ACE 2 receptor, and that's how it gets access to the cells in our body. The cells in our lung have a very high percentage of these receptors. So that in part explains why we're seeing so much lung disease specifically pneumonia and a more severe form of lung injury called acute respiratory distress syndrome in patients who are infected with the Coronavirus. So we've seen a wide range of pathology and patients who are infected from asymptomatic patients, and the ones that we're really focusing on here in the hospital and specifically in the intensive care unit are patients with pneumonia and then acute respiratory distress syndrome, which results in severe hypoxemic respiratory failure.
Host: Well, thank you for that answer. What are some of the ways that Northwestern Memorial Hospitals, Pulmonary Critical Care and Thoracic Surgery is treating patients right now with COVID-19?
Dr. Walter: Thank you. Yeah, that's a great question. I think it starts with very early identification and having a low index of suspicion to think about Coronavirus infection. For patients who are starting to show signs of hypoxemia, our next step is really to think proactively about when patients need more definitive airway management and collaboration with our division and anesthesia and critical care, and thoracic surgery. We've been moving towards fairly early mechanical ventilation in these patients when they get to around five to six liters of nasal cannula. And that's both because we've seen inpatients around that level of support who can develop fairly progressive and rapid hypoxemic respiratory failure, and also to minimize risk of exposure to our staff so that airway management is done in a more controlled situation than a truly crash intubation. Now once patients get to our medical intensive care unit, we really focus on providing evidence based best practice that we would use for all our critically ill patients. So that includes being really thoughtful and looking thoroughly for evidence of coinfection in the mung, including viruses and other bacterial pneumonia is which may be contributing to the patient's decompensation.
And for patients who are starting to develop signs of acute respiratory distress syndrome. What we've really focused on is one, attention to low tidal volume ventilation, so six CCs per kg, ideal body weight with a plateau pressure less than. 30 and what we've noticed early on in a patient's course is that their lungs are actually much more compliant than we see with other causes of acute respiratory distress syndrome. So we're able to ventilate these patients earlier, early on with fairly high low distending pressures that give us reasonable tidal volumes, which is different than other forms of ARDS. And then the other things we focus on are what we do for other ICU patients. Work really closely with our nursing staff and our respiratory therapist to make sure we're on the lowest dose of sedation that's needed to start early and add on nutrition and to use prophylactic treatments for venous thromboembolism and to make sure that we're deescalating lines, and other things that we know are associated with really good outcomes for our critically ill patients.
Host: So Dr. Walter, you mentioned when you decide to initiate mechanical ventilator, you told us when that is, but what about other forms of intervention such as proning or what else are you doing for patients?
Dr. Walter: Sure. So I'm really thrilled to work here at Northwestern where I think we can offer some really cutting edge and evidence based therapies for patients with the most severe hypoxemia as a result of their Coronavirus infection. One thing that I'm particularly proud of is our efforts to provide prone positioning, which is a therapy for patients with severe hypoxemic respiratory failure where we actually turn them into the prone position. So they're facing the floor and we've actually, this has been over a year long quality improvement initiative in our medical intensive care unit where nurses or respiratory therapists and our physicians have really come together to develop evidence based protocols to do this in efficient, safe way for all of our patients. So this has been a really great opportunity to implement this evidence based practice specifically for patients with Coronavirus. I think we're really expert at doing it here. And we've developed protocols that mirror the protocols in Europe where this has been shown to improve survival for patients with ARDS.
So we've already implemented prone positioning in a large number of patients in our medical intensive care unit with Coronavirus and have done that quickly, effectively and with minimal interruptions in patient care and really trying to minimize exposure risk to our providers. And we also have the opportunity to provide extracorporeal membrane oxygenation support. We have very, a really high functioning multidisciplinary collaborative extracorporeal membrane oxygenation support team, which includes members of thoracic surgery, pulmonary critical care, perfusionists, respiratory therapists and physical therapists. So this has been something that's been ongoing for the past several years and it's a very unique time to think about using ECMO in patients with Coronavirus infection to date. We've had two patients on ECMO. We're very careful about who we select to place on ECMO, but I think we're really well positioned to provide that very advanced form of oxygenation support here at Northwestern because of how ingrained our protocols are in our multidisciplinary model of care between surgery and pulmonary critical care.
Host: That's encouraging and very advanced and thank you so much, Dr. Walter. What have been some of the lessons that you've learned along the way in how we're all treating this virus?
Dr. Walter: Yeah, that's a really good question. I think the things that we've learned are to a couple. The first is to be flexible. We learn more every day about the best way to identify and treat these patients and to minimize risk of exposure to clinicians and other staff who are involved in these patient's care. So I think really trying to keep an open mind and be malleable in terms of adapting our practice models. I've been thrilled to watch our entire division from both outside the hospital and the ones at the bedside come together. We've rapidly developed a set of guidelines to follow for care in the intensive care unit, trying to develop consensus among our divisions and our other colleagues in both within the department of medicine, and outside in thoracic surgery about the best way to care for these patients. And I think the continuing to think collaboratively with all the providers about what we're learning and what we can do better, has been a really important lesson. And just being adaptive to changes in patient volume and staffing. I think another really important lesson that we've learned is the just sheer number of anecdotes and information that is out there on social media.
And the peer review literature on potential therapies can be incredibly overwhelming both for clinicians on the ground and for patients and families to try to sift through which of these are best positioned to improve outcomes for our sickest patients. And what I've been, what I've noticed is that here in Northwest and we've really placed an emphasis on doing what we know works, which is really high quality evidence based best practice that we use for our critically ill patients. And then picking the most promising interventions and then studying those, implementing those in a randomized controlled trial. We've picked two, which is remdesivir and then a different medicine, which is an Aisle 6 antagonist that we can enroll patients in randomized controlled trials. So that both gives our patients an opportunity to receive these novel therapies, but also really importantly allows us to learn from the use of these drugs. We can quickly learn what works and what doesn't. And I think that's a really important lesson to not to try to really be thoughtful about these investigational therapies we're using and implementing them in a way that both benefits patients and benefits the scientific community at large.
Host: Well, it certainly does. And as you say, it's so important. That's a great point that you made about being malleable and adaptive because this is certainly something we've not seen before. So how are you safely helping patients get through their treatment without spreading the virus? And talk us through how you and your medical partners are taking precautions to protect yourselves and other healthcare providers while you're giving those treatments.
Dr. Walter: Sure. So we really closely adhere to the recommendations from our hospital leadership on best practice for donning and doffing personal protective equipment for minimizing risk of exposure to staff during aerosolized generating procedures like intubations and bronchoscopies. We cohort currently all of our both suspected infected patients and our confirmed Coronavirus infected patients in specifically designated units within our hospital so that we can have dedicated teams that become really expert at these best practices to minimize infections and minimize the risk of exposure to staff and other patients. So we every day are regrouping on what we know, what we're learning from all of our experience, about the best way to minimize exposure and thinking collaboratively about the making, ensuring we're following those recommendations
Host: As we wrap up, what else do physicians need to know about COVID-19 to manage their patients and when you feel it's really important that they refer to the experts at Northwestern Medicine?
Dr. Walter: Yeah, it's a really good question. I think in terms of, I'll answer the second one first about when to refer to us. You know, we really see ourselves as being well positioned to provide the most advanced life-sustaining treatments for patients specifically with acute respiratory distress syndrome and the potential cardiovascular complications of Coronavirus infection. And like I mentioned before, I think we're really expert at providing ventilation in the prone position, which is a evidence based therapy for ARDS and we're a really high performing center for extracorporeal membrane oxygenation. So for patients who are developing more severe hypoxemic respiratory failure, we really want our other hospitals to reach out to us to one get recommendations on ventilator management and other therapies. And then to think collaboratively with us about would those specific patients benefit from transfer here to implement prone positioning. And I think particularly to think about when to use ECMO for patients with the most severe hypoxemic respiratory failure, which is I think a very unique service that our center does very well.
Host: Do you have any final thoughts about COVID-19 you'd like to share, Dr. Walter?
Dr. Walter: Like you mentioned at the beginning, it's really an unprecedented time to be a patient, to be a patient's loved one, and to be a provider at an academic medical center. I think that the amount we're learning every day, the stress it puts on everyone, both in the healthcare system and outside, it's a lot to handle. And I think here at Northwestern we've taken a lot of comfort in working together, really trying to lean on the sense of community and teamwork that's been stressed every day in meetings and during bedside care, and to never lose sight of that. Our main focus here is to take the best care of all the patients that come through our hospital's doors. So we're really focused on that. And I get the privilege of working with a really wonderful group of providers, both physicians, respiratory therapists, nurses, perfusionists, really wonderful team. And I think that's what gets us through some really difficult times in the hospital.
Host: Well, the multidisciplinary team approach is so important at this time and really all the time. And thank you so much, Dr. Walter for coming on and updating us about what you're doing to treat patients with COVID-19 at Northwestern Medicine. And that concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. To refer your patient or for more information on COVID-19 please visit our website at nm.org to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.