New Treatment Insights for Patients with Severe COVID-19 Illness
In this episode of the Better Edge podcast, James M. Walter, MD, assistant professor of Medicine in the Division of Pulmonary and Critical Care and medical director of the Lung Rescue Program at Northwestern Medicine, discusses how treatment recommendations for patients with severe forms of COVID-19 have evolved since the onset of the pandemic. He also shares several key treatment recommendations. Dr. Walter previously spoke on this topic in a March 2020 podcast: COVID-19 Key Learnings form the ICU.
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Learn more about James Walter, MD
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.Learn more about James Walter, MD
Transcription:
New Treatment Insights for Patients with Severe COVID-19 Illness
Melanie Cole (Host): Welcome to Better Edge a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole. Back in March, Dr. James Walter, Assistant Professor in the Division of Pulmonary and Critical Care and Medical Director of the Lung Rescue Program at Northwestern Medicine, joined us to share the latest in treatment recommendations for some of the most critically ill patients in the ICU.
As we enter into more than 10 months into this COVID-19 pandemic, many of the early protocols and treatment recommendations have drastically changed. Dr. Walter it joining us today to give us an update on the situation. Dr. Walter, it is a pleasure to have you back with us again. Can you share a status update with us on where things are? How have protocols and recommendations changed since you were with us back in March?
James Walter, MD (Guest): Sure. And thanks a lot for having me and giving me a chance to talk about how things have changed here at Northwestern. In terms of a status update in our ICU, we are very busy, but functioning at a I think, a very high level. We consistently have over 30 critically ill patients with COVID-19 in our ICU. This is covered by three dedicated COVID ICU teams. And this is on top of a higher number than normal of critically ill patients in the ICU for reasons other than COVID-19. So, we're quite busy. The silver lining of, like you mentioned such a sustained pandemic, is that right, all members of our ICU team from respiratory therapists and nurses to our physicians and advanced practice providers have gained a tremendous amount of experience and comfort in taking care of these critically ill patients with COVID-19.
So, despite these really high sustained numbers, I think all members of our ICU team feel really well positioned to continue to provide exceptional care to our sickest patients. As far as protocols and recommendations, there's been really an incredible number of publications since we last talked, that have helped us refine our focus in terms of therapeutics and what we should focus on in the ICU. Most notably, in terms of emphasizing which medicines work and which don't. There were so many candidate medications back when we spoke in the spring and so much uncertainty about which of these should be prioritized for our patients newly admitted to the ICU. We know now, clearly, that the most beneficial of these medicines for critically ill patients is a steroid dexamethazone.
So, that's the medicine that we are really prioritizing for our ICU patients. We're also using, feel much more comfortable using respiratory support, like high flow nasal cannula, which there was a lot of concern early on about the risks to providers, in spreading COVID-19 for patients who are on high flow nasal cannula. So, we've actually used a lot more of this, and this has I think saved a lot of patients from going on the mechanical ventilator.
Host: What about ECMO, Dr. Walter?
Dr. Walter: Yeah, that's a great question. I think what we've learned, since we spoke in March is that ECMO when used at a high volume expert center, which I think Northwestern really is, can prove to be lifesaving in very carefully selected patients with COVID-19. The data to date shows that in these high volume centers like Northwestern, patients with severe ARDS from COVID-19, who are placed on ECMO, have similar outcomes to patients who are placed on ECMO for ARDS not in the setting of COVID-19. So, I think emphasizing that when used at a high volume center, ECMO can truly be a lifesaving, supportive device.
Host: Dr. Walter, as you're telling us and giving us this update and telling us what you've learned, because, I mean, in so many ways, this virus is still a mystery, but you all amaze me. And the things that you have come up with. Is prone positioning, still a technique that's being used. Please discuss the BMJ study that outlined the risk of peripheral nerve injury. Tell us what you've learned, Dr. Walter.
Dr. Walter: Sure. So, I think prone positioning is still certainly a key tool for us in the intensive care unit. When we think about the management of patients with severe ARDS from COVID 19, after the implementation of evidence-based practices for ARDS, low tidal volume ventilation, low distending pressures, an adequate trial of peep, we've been very quick to implement prone positioning for our sickest patients with COVID-19 associated ARDS.
So, I think, like in March, certainly true still today that prone positioning is a core component of our management of our sickest COVID-19 patients. We have learned some interesting things since we last spoke about the potential downstream effects of a prone positioning that because patients spend up to 16 hours per day in the prone positioning, coupled with a potential effect of the SARS COV2 virus, there is a higher number than we would expect of patients who down the road experience peripheral neuropathies and nerve injuries, after a really long ICU stay. And we've had some great collaboration with our colleagues over at Shirley Ryan, trying to learn from our experience with these patients, both in why this might be happening, how to prevent it, and then best management once these patients leave the hospital and go into a rehab facility. So, it hasn't changed our focus on prone positioning, but this data has pushed us to refine our prone positioning protocols to really focus on these areas that are most susceptible to nerve injury, to try to offload these pressure areas when patients are in the prone positioning, and then continuing to partner with our colleagues over at Shirley Ryan, to focus on these areas as a patient transitions to the rehab setting.
Host: So, over the summer, the Northwestern Medicine team performed the first double lung transplant on a patient with irreversible lung damage. Dr. Walter, speak to us a little bit about when transplantation would be considered an option and is Northwestern Medicine consulting with physicians across the country and accepting referrals? Tell us about how this is working its way around the country, so that you're all looking to each other and then speak to us about that very exciting double lung transplant.
Dr. Walter: Yeah, this is certainly an area where Northwestern Medicine is leading the way, not just nationally, but internationally in terms of thinking about and using lung transplantation for patients with really end-stage complications of COVID-19. Our transplant team led by Ankit Bharat in thoracic surgery and Rade Tomic our Medical Director of Lung Transplant, have really convincingly shown that at a center like ours, with a really high functioning lung transplant team; that transplant can be a life saving option for patients who otherwise really do not have, an avenue to get off of a mechanical ventilator and to get out of the intensive care unit. So, our transplant team has been taking calls and referrals from around the country, including for patients on ECMO who have been transferred to our center for evaluation.
The key here is this, is an a really carefully selected subset of patients with end stage complications of COVID-19 and our lung transplant team puts a lot thought into how to best select these patients to ensure that after transplant patients are best set up for success, but we really have been leading the way and showing that transplant can be effectively used for some of these really sick patients.
Host: Such a challenging time for all of you. And one of the challenging aspects is the unpredictable and vast presentation of symptoms that we're hearing about it seems every day, different ones, Dr. Walter. Now we're nearly a year into this. Have there been any common themes? What have you found that seems to be more of a common thread? Please discuss some of the ones that have surprised you.
Dr. Walter: Yeah, I think the most common thread is to expect the unexpected. That the many you expect every patient with COVID-19 to present in a predictable way, you get surprised by patients who have primarily dermatologic manifestations of their disease or pulmonary manifestations, but a couple of weeks after developing COVID-19, have multi-system signs of inflammation like carditis, hepatitis. So, I think we've really lowered our threshold to test and to consider the possibility of SARS COV2 as being a potential cause for a truly myriad number of presentations for patients coming into the hospital. So, I think that's been the main message is that you're constantly surprised and you should have an extremely low almost no threshold to test for the SARS COV2 virus.
The other sort of main take-homes is that recovery can be quite long. So, especially for our ICU patients, we've seen really long rocky courses. So, to try to set that expectation with families that recovery can take quite a while, and that even early on setbacks and severe critical illness, doesn't mean that patients do not have the potential to get better after a long ICU stay with really attentive evidence-based critical care.
Host: Let's discuss that before we wrap up Dr. Walter, we're hearing more about long haulers and long-term symptoms and complications. Can you speak about treatment recommendations? This is new, that you're learning because it's only been around for nine months or so. Speak about what you're doing for those long haulers and how Northwestern Medicine is offering unique options for these patients.
Dr. Walter: Yeah, that's a great question. And it's an area like you mentioned, that's still dominated by much more uncertainty than what we know. So, it's a really unique opportunity to work with colleagues in Neurology and colleagues over at the Shirley Ryan AbilityLab on how to learn from these patients and how to best care for them.
So, we're still learning a lot about what we can expect after a prolonged critical illness, but we have I think come up with a couple of themes. One that I mentioned already is that we've seen nerve injury and muscle weakness that can persist for a long time after critical illness. And my colleagues at Shirley Ryan have come up with a lot of really novel imaging techniques and potential therapeutics to try to identify these nerve injuries and help patients on the road to recovery.
We've been quick to use diaphragm ultrasound and we're actively learning from and studying our cohort of patients who go to Shirley Ryan and to try to create our best protocols to set these patients up for success. There's a number of different clinics too, that are getting patients who have left the hospital back into a care setting to make sure that everything is progressing as we expect. Our Neurology colleagues have a robust post COVID clinic that is caring for patients in the Outpatient setting.
Melanie Cole (Host): So, what would you like other providers to take away from this update today Dr. Walter? Speak about how this multidisciplinary care at Northwestern Medicine is really making such a difference in so many patient's lives and what you'd like them to know about how you are all handling this.
Dr. Walter: Yeah, it's a great question. I think the main take homes that we've seen that it's similar to in March, that it's this is really a team-based effort and it's a privilege to get to work at a place like Northwestern Medicine that has truly exceptional team members across the spectrum of Hospital Medicine into Critical Care and the Outpatient setting like we've talked about.
So, I think our patients who are cared for here, benefit from expertise across providers, from respiratory therapists and nurses who have been doing this for months and months and months, to ICU providers, and then out into the Outpatient setting. Team members, like our colleagues at Shirley Ryan and Neurology who are actively studying and trying to give these patients in the Outpatient setting the best possible care.
Host: It's great information. Just absolutely fascinating. And thank you so much for coming on Dr. Walter and sharing your update with us. And I hope you'll come back on again in a few months and update us as you learn more. Thank you again for all the great work that you're doing. To refer your patient, or for more information on COVID-19, please visit our website at nm.org/pulmonary to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. Until next time, I'm Melanie Cole.
New Treatment Insights for Patients with Severe COVID-19 Illness
Melanie Cole (Host): Welcome to Better Edge a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole. Back in March, Dr. James Walter, Assistant Professor in the Division of Pulmonary and Critical Care and Medical Director of the Lung Rescue Program at Northwestern Medicine, joined us to share the latest in treatment recommendations for some of the most critically ill patients in the ICU.
As we enter into more than 10 months into this COVID-19 pandemic, many of the early protocols and treatment recommendations have drastically changed. Dr. Walter it joining us today to give us an update on the situation. Dr. Walter, it is a pleasure to have you back with us again. Can you share a status update with us on where things are? How have protocols and recommendations changed since you were with us back in March?
James Walter, MD (Guest): Sure. And thanks a lot for having me and giving me a chance to talk about how things have changed here at Northwestern. In terms of a status update in our ICU, we are very busy, but functioning at a I think, a very high level. We consistently have over 30 critically ill patients with COVID-19 in our ICU. This is covered by three dedicated COVID ICU teams. And this is on top of a higher number than normal of critically ill patients in the ICU for reasons other than COVID-19. So, we're quite busy. The silver lining of, like you mentioned such a sustained pandemic, is that right, all members of our ICU team from respiratory therapists and nurses to our physicians and advanced practice providers have gained a tremendous amount of experience and comfort in taking care of these critically ill patients with COVID-19.
So, despite these really high sustained numbers, I think all members of our ICU team feel really well positioned to continue to provide exceptional care to our sickest patients. As far as protocols and recommendations, there's been really an incredible number of publications since we last talked, that have helped us refine our focus in terms of therapeutics and what we should focus on in the ICU. Most notably, in terms of emphasizing which medicines work and which don't. There were so many candidate medications back when we spoke in the spring and so much uncertainty about which of these should be prioritized for our patients newly admitted to the ICU. We know now, clearly, that the most beneficial of these medicines for critically ill patients is a steroid dexamethazone.
So, that's the medicine that we are really prioritizing for our ICU patients. We're also using, feel much more comfortable using respiratory support, like high flow nasal cannula, which there was a lot of concern early on about the risks to providers, in spreading COVID-19 for patients who are on high flow nasal cannula. So, we've actually used a lot more of this, and this has I think saved a lot of patients from going on the mechanical ventilator.
Host: What about ECMO, Dr. Walter?
Dr. Walter: Yeah, that's a great question. I think what we've learned, since we spoke in March is that ECMO when used at a high volume expert center, which I think Northwestern really is, can prove to be lifesaving in very carefully selected patients with COVID-19. The data to date shows that in these high volume centers like Northwestern, patients with severe ARDS from COVID-19, who are placed on ECMO, have similar outcomes to patients who are placed on ECMO for ARDS not in the setting of COVID-19. So, I think emphasizing that when used at a high volume center, ECMO can truly be a lifesaving, supportive device.
Host: Dr. Walter, as you're telling us and giving us this update and telling us what you've learned, because, I mean, in so many ways, this virus is still a mystery, but you all amaze me. And the things that you have come up with. Is prone positioning, still a technique that's being used. Please discuss the BMJ study that outlined the risk of peripheral nerve injury. Tell us what you've learned, Dr. Walter.
Dr. Walter: Sure. So, I think prone positioning is still certainly a key tool for us in the intensive care unit. When we think about the management of patients with severe ARDS from COVID 19, after the implementation of evidence-based practices for ARDS, low tidal volume ventilation, low distending pressures, an adequate trial of peep, we've been very quick to implement prone positioning for our sickest patients with COVID-19 associated ARDS.
So, I think, like in March, certainly true still today that prone positioning is a core component of our management of our sickest COVID-19 patients. We have learned some interesting things since we last spoke about the potential downstream effects of a prone positioning that because patients spend up to 16 hours per day in the prone positioning, coupled with a potential effect of the SARS COV2 virus, there is a higher number than we would expect of patients who down the road experience peripheral neuropathies and nerve injuries, after a really long ICU stay. And we've had some great collaboration with our colleagues over at Shirley Ryan, trying to learn from our experience with these patients, both in why this might be happening, how to prevent it, and then best management once these patients leave the hospital and go into a rehab facility. So, it hasn't changed our focus on prone positioning, but this data has pushed us to refine our prone positioning protocols to really focus on these areas that are most susceptible to nerve injury, to try to offload these pressure areas when patients are in the prone positioning, and then continuing to partner with our colleagues over at Shirley Ryan, to focus on these areas as a patient transitions to the rehab setting.
Host: So, over the summer, the Northwestern Medicine team performed the first double lung transplant on a patient with irreversible lung damage. Dr. Walter, speak to us a little bit about when transplantation would be considered an option and is Northwestern Medicine consulting with physicians across the country and accepting referrals? Tell us about how this is working its way around the country, so that you're all looking to each other and then speak to us about that very exciting double lung transplant.
Dr. Walter: Yeah, this is certainly an area where Northwestern Medicine is leading the way, not just nationally, but internationally in terms of thinking about and using lung transplantation for patients with really end-stage complications of COVID-19. Our transplant team led by Ankit Bharat in thoracic surgery and Rade Tomic our Medical Director of Lung Transplant, have really convincingly shown that at a center like ours, with a really high functioning lung transplant team; that transplant can be a life saving option for patients who otherwise really do not have, an avenue to get off of a mechanical ventilator and to get out of the intensive care unit. So, our transplant team has been taking calls and referrals from around the country, including for patients on ECMO who have been transferred to our center for evaluation.
The key here is this, is an a really carefully selected subset of patients with end stage complications of COVID-19 and our lung transplant team puts a lot thought into how to best select these patients to ensure that after transplant patients are best set up for success, but we really have been leading the way and showing that transplant can be effectively used for some of these really sick patients.
Host: Such a challenging time for all of you. And one of the challenging aspects is the unpredictable and vast presentation of symptoms that we're hearing about it seems every day, different ones, Dr. Walter. Now we're nearly a year into this. Have there been any common themes? What have you found that seems to be more of a common thread? Please discuss some of the ones that have surprised you.
Dr. Walter: Yeah, I think the most common thread is to expect the unexpected. That the many you expect every patient with COVID-19 to present in a predictable way, you get surprised by patients who have primarily dermatologic manifestations of their disease or pulmonary manifestations, but a couple of weeks after developing COVID-19, have multi-system signs of inflammation like carditis, hepatitis. So, I think we've really lowered our threshold to test and to consider the possibility of SARS COV2 as being a potential cause for a truly myriad number of presentations for patients coming into the hospital. So, I think that's been the main message is that you're constantly surprised and you should have an extremely low almost no threshold to test for the SARS COV2 virus.
The other sort of main take-homes is that recovery can be quite long. So, especially for our ICU patients, we've seen really long rocky courses. So, to try to set that expectation with families that recovery can take quite a while, and that even early on setbacks and severe critical illness, doesn't mean that patients do not have the potential to get better after a long ICU stay with really attentive evidence-based critical care.
Host: Let's discuss that before we wrap up Dr. Walter, we're hearing more about long haulers and long-term symptoms and complications. Can you speak about treatment recommendations? This is new, that you're learning because it's only been around for nine months or so. Speak about what you're doing for those long haulers and how Northwestern Medicine is offering unique options for these patients.
Dr. Walter: Yeah, that's a great question. And it's an area like you mentioned, that's still dominated by much more uncertainty than what we know. So, it's a really unique opportunity to work with colleagues in Neurology and colleagues over at the Shirley Ryan AbilityLab on how to learn from these patients and how to best care for them.
So, we're still learning a lot about what we can expect after a prolonged critical illness, but we have I think come up with a couple of themes. One that I mentioned already is that we've seen nerve injury and muscle weakness that can persist for a long time after critical illness. And my colleagues at Shirley Ryan have come up with a lot of really novel imaging techniques and potential therapeutics to try to identify these nerve injuries and help patients on the road to recovery.
We've been quick to use diaphragm ultrasound and we're actively learning from and studying our cohort of patients who go to Shirley Ryan and to try to create our best protocols to set these patients up for success. There's a number of different clinics too, that are getting patients who have left the hospital back into a care setting to make sure that everything is progressing as we expect. Our Neurology colleagues have a robust post COVID clinic that is caring for patients in the Outpatient setting.
Melanie Cole (Host): So, what would you like other providers to take away from this update today Dr. Walter? Speak about how this multidisciplinary care at Northwestern Medicine is really making such a difference in so many patient's lives and what you'd like them to know about how you are all handling this.
Dr. Walter: Yeah, it's a great question. I think the main take homes that we've seen that it's similar to in March, that it's this is really a team-based effort and it's a privilege to get to work at a place like Northwestern Medicine that has truly exceptional team members across the spectrum of Hospital Medicine into Critical Care and the Outpatient setting like we've talked about.
So, I think our patients who are cared for here, benefit from expertise across providers, from respiratory therapists and nurses who have been doing this for months and months and months, to ICU providers, and then out into the Outpatient setting. Team members, like our colleagues at Shirley Ryan and Neurology who are actively studying and trying to give these patients in the Outpatient setting the best possible care.
Host: It's great information. Just absolutely fascinating. And thank you so much for coming on Dr. Walter and sharing your update with us. And I hope you'll come back on again in a few months and update us as you learn more. Thank you again for all the great work that you're doing. To refer your patient, or for more information on COVID-19, please visit our website at nm.org/pulmonary to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. Until next time, I'm Melanie Cole.