"PCCSM Clinical Updates 2021" Jonathan Siner, etc.. (02.10.2021)

February 26, 2021

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00:00Alright, OK, well we'll get started.
00:04We have a fairly lengthy program,
00:06so we'll get on with it.
00:09So thanks everyone for joining.
00:11This is this is in the time slot.
00:14It is an adapted form of a motorcycle care,
00:18Sleep Medicine, grand rounds.
00:21It's a little departure
00:22from our usual format.
00:23We're doing a lot of focus core
00:26topics with the idea that a lot of
00:28us only present at grand rounds or
00:30other formats to our colleagues,
00:32peers and the Medical Center,
00:34sort of in larger topics.
00:35And we don't get a chance to
00:37educate peers and everyone else on
00:39some focus but important topics.
00:41And so we have a group of us and
00:43we hope to have some feedback.
00:46I'm not going to do a survey,
00:48but we interest in people's
00:50feedback on how this works.
00:51Odd and decide whether we
00:53wouldn't want to do it again.
00:55So with that we'll get started.
01:15So thank you for joining us.
01:17This is PC FM clinical updates 2021.
01:20I'm just going to just show you the
01:23schedule so you know what's coming.
01:25So I'll start off talking about
01:27cardiac arrests and Doctor Hunt is
01:29going to talk about the acute airway
01:32management followed by Doctor in.
01:33Those are just talking about Antifibrotic
01:35Sinan interstitial lung disease.
01:37Doctor Chowski talking about.
01:40The Yale Interventional pulmonary
01:41approach to chest tubes and TPA.
01:44Doctor Rochester has been working for
01:46a long time with a group on SEO period
01:49missions will give us some updates on that.
01:51Doctor Singh or pulmonary
01:53hypertension experts has a particular
01:54device he likes to use,
01:56is used frequently and a lot of your patients
01:58referred him or getting tested on it,
02:00so I thought it would be worth
02:03understanding that further doctor
02:04Chitra who is the medical director for
02:06the Chronic Respiratory Unit on 10
02:08seven will give us some updates about.
02:11Chronic ventilator we need,
02:12and then she'll come back with Doctor
02:15Dibiase talk a little bit about successful
02:18weaning that results in Decannulation.
02:20Doctor Cough will be updated on cystic
02:22fibrosis Doctor Khosla or intense.
02:24This will be talking about pulmonary
02:26embolism response team and will close
02:29it out with an update on the ever
02:31popular post Covid care in clinic.
02:34So in terms of disclosures,
02:35so we don't have to repeat it.
02:37Everybody said they have no disclosures
02:39except for Doctor Rochester,
02:40Entornos orcas have reviewed it medicine,
02:42and they have been reconciled.
02:44Thank you.
02:46So just talk briefly about something
02:49that was particularly interesting to
02:51me through my patient safety lens,
02:53which was.
02:55The unexpected cardiac arrests in
02:57the medical intensive care unit.
02:59And just going stepping back for
03:01a moment about patient safety.
03:03The biggest study and probably
03:04the most interesting,
03:05was at the Brooklyn Hospital in 2005,
03:08was published in 2005,
03:09and they looked at this because they
03:11theorize that ICU patients had higher
03:13adverse event rates and both from the
03:16interventions and the severity of illness.
03:18The risk would be higher
03:20and they basically did a.
03:22A survey of all the ICU,
03:24MICU and CCU patients from 2000 to
03:272003 and looked at many different
03:29ways to look at adverse events.
03:31Voluntary reporting which is the online
03:33systems were used to computer order entry.
03:36They actually extracted charts
03:38and they literally had.
03:40Students,
03:41an observers roaming around the ICU
03:43looking for problems and we don't
03:45need to get into all the details but
03:47the results as they showed you know,
03:49basically over 220 adverse events
03:51for every thousand patient days.
03:53Serious errors address, which is a lot,
03:55so it's something basically if you
03:57have way patient for five days in the
04:00year to have something significant warrants.
04:02And so I'm talking about that
04:04'cause the question is why?
04:06And it's mostly has to do with
04:08risk and degree of intervention.
04:10So just in thinking about that,
04:12were wondering what is going
04:13on in the ICU as
04:15people know there's an extensive
04:17literature rapid response teams
04:19that seem to reduce cardiac arrest.
04:21Sandy compensations outside
04:22the icy population.
04:23So it's a pretty well developed
04:25concept outside the ICU,
04:26but we had a re admission
04:28project from a couple years ago
04:31where we noted that sort of.
04:33Practice around Bipap and after people
04:35recovering from respiratory failure was
04:38was all different than what we expect
04:40and there was room for improvement so.
04:42We began to wonder if there are
04:44some other opportunities in the ICU
04:46when you think about intensive care,
04:48people presume that sort of general
04:50monitoring is adequate that patients
04:52are sort of already getting what
04:54we call maximal care.
04:55So something is wrong.
04:57There may be nothing else
04:59that could have been done.
05:01Um, and then I think there's a general bias,
05:05probably.
05:05For people outside the IC less than
05:08those who spend time in the ICU,
05:11but the critical care patients
05:13are like Diane,
05:14that we sort of normalize cardiac arrests.
05:16Another severe outcomes and
05:18the questions is that true?
05:19So what do we know about in
05:22hospital cardiac arrest?
05:23More than half occur in intensive care unit,
05:26100,000 a year the actually the
05:28outcomes in ICU's are better,
05:30but that's probably some selection
05:32bias related DNR status for the
05:34sickest of the sick patients.
05:36And just a reminder that most IC
05:38deaths occur after decision to
05:39withdraw care rather than cardiac arrest,
05:41because we generally know who's
05:43not going to survive.
05:45Um,
05:45there was a systematic review down
05:47that said there were about 22.5
05:50in hospital cardiac arrest per
05:52thousand admissions ICU patients,
05:54and it's been stable overtime and
05:57about 70% survived hospital discharge,
05:59which is surprisingly good.
06:01And if you looked at that,
06:04that would give for the York
06:06Street campus ICU about 6162.
06:09Ice cardiac arrests per year.
06:12And so we looked at 2017,
06:14and in fact we that's what we found in 2017.
06:17We looked at all the cardiac arrests.
06:19Karen Marlette,
06:20one of our IPS worked on this
06:22with me and she reviewed actually
06:24all the charts we had 6128 not
06:26survive the surprise link.
06:2836 Survived the arrest and
06:30ultimately five were discharged.
06:32And it sort of categorized
06:34them into different buckets.
06:35And there were a variety of causes,
06:38and I'm not going to go
06:40through every single one.
06:41Notice end of life, meaning there were.
06:44Essentially, it was recognized.
06:45The patient was going to rest,
06:47and the patient was still full.
06:49Code was only 8%,
06:51so a fair number were unexpected.
06:53Hence the title of this presentation
06:55somewhere hemodynamic collapse.
06:56But we were interested in so somewhere
06:58reversible based on clinical judgment,
07:00but the two other most
07:02frequent ones were acidosis.
07:03And hypoxemia,
07:04and this is just a chart looking
07:06showing what the was going on from
07:08a respiratory therapy standpoint
07:10at the time the cardiac arrest.
07:11And I would just point out couple things.
07:14There were only three of them
07:16were on ventilators.
07:17Probably the people arrest
07:18on ventilators or you are.
07:21Not fair number. We're on by path and
07:23a fair #1 high flow nasal cannula,
07:25and those are the ones who survive
07:27so the ones on ventilator seems
07:29to be less likely survived.
07:31But you notice there are number of survivals
07:33and a lot of the moron CPAP or Bipap.
07:39And so, looking at the acidosis category,
07:41you identified several themes.
07:43One was failure to repeat
07:45elevated lactic acid,
07:46one was not using bicarbonate therapy
07:48while waiting for CVH initiation,
07:50and there were alot around sort of
07:53not adjusting for a respiratory rate
07:55because we tend to sideline that and
07:58not think about what a patient would
08:00be doing when they're acutely ill.
08:04With utilization of Bipap for medical
08:06acidosis and three out of the seven survived,
08:09so that was our data and we were pretty
08:13fascinated because there was clearly to
08:16stand out certain acidosis and in terms of.
08:19Management of sick patients on
08:21Bipap and high flow so you know
08:23you can always wonder if you do.
08:25A local study,
08:26is it just sort of local practice?
08:28But then this came out of Beth Israel
08:31Deaconess from somebody some of you know.
08:33Basically, they looked at the same.
08:35Basically the same group and their ICU.
08:37So it was not restricted to the MCU and
08:40they reviewed all the cases with the panel.
08:44And essentially what they found was.
08:47And in the 40 three that they reviewed,
08:50the age was the same between the
08:52preventable in the non preventable
08:54ones and a fair number on vasopressors
08:57of the preventable ones.
08:58Fewer ones were on mechanical ventilation,
09:00which is matches up with our data.
09:03They tend to be earlier in their house
09:06ICU stay and they got a fairer Oscan.
09:09A fair number of them and a fair
09:11number of the ones that they had
09:13categorized blindly as preventable
09:15actually survived hospital discharge.
09:17And this basically was a similar
09:19plot for their group,
09:21and so timing of response deterioration,
09:23which included included for them,
09:24respiratory failure,
09:25response to that and you can see that
09:28they have both acidosis and timing
09:30information in their top group.
09:31So we're we're really encouraged by
09:33this that the finding was not just one,
09:36often in our particular population,
09:38that sort of started to motivate us.
09:40This came out right before the pandemic
09:42and we were sort of reviewing our data
09:45for an intervention at that point.
09:48So in summary,
09:49in ICU cardiac arrests are excellent
09:51target for quality improvement efforts
09:53and improved understanding of ice.
09:55You care delivery specifically,
09:56both our study and and the one from Bethel.
10:00Going to show that the acidosis and in
10:03particular respiratory failure groups,
10:05fair number of the patients,
10:07actually survive,
10:08suggesting that that there's an
10:10opportunity to actually prevent it.
10:12If you looked up stream,
10:14and in particular what we recognized
10:17was troops,
10:18the patients who were in multisystem
10:20organ failure, so shock renal failure.
10:24Anne,
10:24with an acidosis were likely
10:27to arrest and similarly,
10:29particularly on patients in high
10:31flow and Bipap who were becoming
10:33academic on pressers in renal failure,
10:36in particular when it was used
10:40for hypoxemic respiratory failure
10:42with FI 2 / 80% and so that was
10:46really the group to target.
10:49And so the other piece just going
10:51back to my comment about our re
10:53admission work was that we had
10:54also noted that there were some
10:56gaps related to understanding of
10:58respiratory failure with ICO Re
10:59admissions and I think what we learned
11:01here is that we tend to learn sort
11:03of these things very informally,
11:05but we actually a lot of this.
11:07A lot of these things that we learn
11:09or lacking the real specifics to
11:11allow us to make precise decisions.
11:12And it's not that people's clinical
11:14judgment is not good is that there there
11:17is data that they have not been provided.
11:19Um, so very specifically related to acidosis,
11:23we're going to sort of work on some
11:27education structural changes in our workflow.
11:30And so we're going to.
11:32We're going to distribute
11:33this right before COVID-19,
11:34but we did not,
11:35so we're probably going to work
11:37on this the next month or two,
11:39which is sort of some guidelines around this.
11:41And again,
11:42people on Bipap were very hypoxemic.
11:45Or high flow for prolonged period of time you
11:48have to be very careful if they are changing.
11:51If they cannot tolerate particularly
11:53coming off of Bipap at all,
11:54or their FI two is high there,
11:57there at very high risk of arrest.
12:00So that's one of the pieces
12:02that we're going to focus on.
12:04Both sort of education.
12:05So this is the start of that,
12:07and then some other embedding,
12:09some alerts and other things both
12:11in the workflow with respiratory
12:12and also within the EMR.
12:17Support. So if you have questions,
12:20we ask people to put them in.
12:23In the chat room and then we
12:25sort of go on from there. Say.
12:29And so next is Doctor Show Kanadan
12:31talking about 5 things you should
12:33know about Tart activations,
12:35which those of you don't know what part is.
12:38That is the 2nd for Advanced Airway
12:40Team threatened airway response.
12:42Team choco. I
12:44grew up here. Let me bring up my screen.
12:54Now I'm done. Now I'm not done alright,
12:56I will start from the beginning.
13:00Lungs start OK. Alright,
13:05so I'm just gonna take a few minutes
13:09either just tips about participation.
13:15So I'm going to start by
13:17asking you a question,
13:19what do these things have in common?
13:21Will just look up some pictures.
13:26Tsunami familiar to me coming from Japan.
13:30Pandemic. And then.
13:34And the airway crisis. And really,
13:38the point here is that these are.
13:42Low frequency high risk events.
13:48And I think it's worthwhile
13:50thinking about this airway crisis.
13:52It's not, thankfully,
13:53something we have to deal with very often,
13:56but when it happens, it's pretty scary.
13:59So here's 5 things you should
14:02know about Otard activation.
14:03I'm just going to quickly go through The Who,
14:07what, and why of parts just to
14:10keep this fresh in your mind.
14:13So what is start as Doctor Siner said,
14:17it is short for threatened adult airway
14:20response response team and the criteria
14:22for activation are really just two things
14:25and really think of this as an airway code,
14:28doctor sign or just spoke
14:31about cardiac grass.
14:32But these are sort of.
14:35A lead up to a potential
14:37cardiac arrest and airway code.
14:40So someone with cardio,
14:42pulmonary compromised,
14:43paired with your perception than an airway
14:46will be difficult by conventional techniques.
14:50Now, historically predicting a difficult
14:51airway is much easier said than done,
14:54so these are not like the is it,
14:57or is it not going to be a
15:00difficult airway situation?
15:01These are patients who should
15:04have fairly obvious.
15:05Clinical factors that you are visible
15:08to you or are relevant in the history.
15:11This might be the patient with clear
15:15anatomical distortion or the patient
15:18on the right here who has known.
15:21Oral pharyngeal malignancy, for example.
15:26From a practical perspective,
15:28how do you activate Tart in
15:30our healthcare in our system?
15:32So a simple 155 call,
15:34the operator notifies that our team
15:37overhead an via phone and text.
15:39For those of you walking around in the MCU,
15:43but you'll see,
15:44here is something like a medical
15:46alert threatened airway response team
15:48adult York Street campus MP9 MCU room,
15:51blah blah blah.
15:53Now what do you do if it's
15:55not quite at that level?
15:58Meaning you are not faced with
16:00someone who has rapidly unstable
16:02saturations or hemodynamics,
16:03and you have a few minutes to really
16:06think through what the optimal plan is.
16:09There are, if it's not a true
16:12I need all hands on deck now,
16:15emergency.
16:15The best way to really powwow
16:17would be to actually make a
16:20direct call with the anesthesia
16:22attending and these are some of
16:25the numbers you can use for the
16:27SRC campus as well as York Street.
16:32So then you call 155,
16:34who actually comes when you activate a tart.
16:38There are some campus differences versus
16:40York Street versus SRC York Street.
16:42You get your anesthesia attending
16:44and this is a pre specified person
16:47who knows they are going to be up.
16:50If there's a tart activation.
16:53An anesthesia resident again.
16:55I pre identified as the
16:58emergency code resident.
17:00A trauma surgeon and E NT resident
17:03and ET attending if available and
17:05their availability is variable
17:07depending on whether the,
17:09whether it's after hours or whether
17:11they are in a case already in the OR
17:15SWAT nurse respiratory therapist.
17:16So what the SRC campus?
17:18There are a couple differences which
17:21is relevant and for us who go over
17:24and spend some time in SRC you should
17:27know you will get an anesthesia attending.
17:31A Crna as available an in-house
17:33kind of this replaces the extra
17:35pair of anesthesia hands that would
17:37have been otherwise.
17:39Anesthesia resident on
17:41the York Street campus.
17:43Surgical attending on call
17:45again as available an in house.
17:49Daytime staffing is pretty adequate
17:52night time and weekend staffing
17:55is variable at this RC campus.
17:58There will always be a senior
18:01surgical resident that arrives.
18:03E NT attending Andor resident
18:04may or may not be available,
18:07which really means,
18:08in terms of a surgical pair of hands,
18:11this senior resident might be
18:13the only person who shows up to
18:16a tart at SRC micu attending.
18:18I guess I expected to come.
18:21SWAT nurse Micu nurse and secures
18:23along with a respiratory therapist.
18:29So then what actually comes to
18:31you when you activate a car,
18:33in addition to all those bodies?
18:35Again, the point of a tart code
18:38is really to get all the equipment
18:40and the right personnel in
18:42the room within a few minutes.
18:44At York Street,
18:45there is an adult art cart with
18:48supplies needed for a difficult
18:50intubation as well as a surgical
18:52airway that will be brought up from the
18:55South pavilion OR by the anesthesia team.
18:58Or another member of the
18:59anesthesia team was appropriate
19:01and available at the SRC campus.
19:03A similar cart is available
19:05near the very second floor.
19:07Oh are holding area and that
19:09equipment is brought to the bedside
19:11by the Sicu nurse who responds.
19:16I was always taught that whenever you
19:20are dealing with an airway emergency.
19:23Always always you should have
19:25a Plan B and plan C anaplan D
19:28If you can come up with some.
19:30Because these are again really rare events
19:33that is hard to really think through.
19:36Unless you feel you have some
19:39next steps in mind.
19:42So just as an aside,
19:44fairly recently we had a tart code
19:47in the MCU where unfortunately
19:50the wrong tart cart came up.
19:54There are New York street carts
19:57that are in the South Pole.
20:00You know our next to that art cart
20:03was a cart that looked just like it,
20:05but for a different purpose.
20:07And unfortunately that cart came up,
20:09which didn't have all of the
20:11equipment that we needed.
20:13Anne.
20:14There are also other factors
20:17that can actually come to play
20:19which would just to say that in
20:23forward these infrequent events,
20:25wherever you're working for those
20:27of you who are actually logging in
20:30from another facility, it is really,
20:33really helpful and eye opening.
20:36I think to be familiar with
20:38your emergency equipment.
20:40So though, as I said,
20:42getting back to the case.
20:45The the unfortunately the wrong cart came up,
20:48which meant that there was a
20:51different tracheostomy set,
20:52as well as some missing adapter
20:55supplies for the tart activation
20:57that happened in the MCU,
21:00and as it turns out,
21:02there are many different versions of
21:04tracheostomy sets in the hospital.
21:07Some strangely, has a handle, but no blade.
21:10This is being rectified,
21:12as is the situation with.
21:15Proper labeling of that art card so
21:18you know there's always an emergency
21:21tracheostomy tray available in the MCU.
21:25There should be scalpels as well,
21:27but if in doubt the one piece that
21:30became a really contentious piece of
21:33equipment that was missing during our
21:36recent arc code was actually a scalpel.
21:39Just remember,
21:40there's always actually scalpel
21:42supplies in every single one of those
21:45red crash cards on the 1st drawer.
21:48If you look really,
21:51really carefully.
21:53Thankfully, as I said,
21:54tart activations are fairly rare,
21:56although there are some peaks and
21:59valleys here.
22:00This covers a period of about 18 months.
22:03There are there are on average,
22:05four to five tart activations per
22:08month and the vast vast majority
22:10do not require surgical airway,
22:12but the multidisciplinary
22:14conversation that happens is really
22:16what is needed and can be really
22:18helpful when you have a patient
22:21that you have concerns about.
22:24So that's all I've got.
22:29And I will let Doctor Siner move on.
22:33How come I don't see anything in the
22:35chat so we go onto Doctor Ano Circus,
22:38Danielle talking about Antifibrotic Sen
22:41interstitial lung disease. Thanks Jonathan.
22:45So let me just share my screen here.
22:55OK, so I thought that I would talk
22:57about this kind of onward to outpatient
22:59management as opposed to some of the
23:02inpatient topics we've heard about.
23:03Because I definitely get a
23:05lot of questions about this,
23:07and these are all medications or two
23:09medications that really nobody learned
23:11about in medical school 'cause they were
23:13fairly recently approved by the FDA.
23:15So I'll start by talking a little
23:17bit about their role in IPF or
23:19idiopathic pulmonary fibrosis.
23:21And this is, I think,
23:22a good indication as to why
23:24there needed this is a.
23:26A sense for what happens to patients
23:28overtime and patients tend to
23:30progress gradually in most cases,
23:32sometimes slowly, sometimes more quickly,
23:33and then in Kirby.
23:35What you see is also some patients have
23:37what's known as an acute exacerbation
23:39where they have a sudden worsening,
23:42and you can imagine that a medication
23:44that is helpful in IPF would
23:46either slow down the progression,
23:48but obviously it would be nice
23:50if it halted it altogether,
23:52but ideally, if that wasn't possible,
23:54would slow the progression.
23:55So maybe take the curve from A to
23:58D or even A to see would be an
24:01advantage and potentially would
24:03prevent an acute exacerbation.
24:05And these sudden declines that you can see.
24:09So there are two medications that are
24:12currently approved prophetic tone,
24:14also known as as retana.
24:16Tentative, known as 05.
24:17They're both oral medications
24:18and they have multiple targets,
24:20which may be one of the reasons that
24:23basically effective because they're
24:25getting different aspects in preventive case.
24:27Did you have data and Tina Falfa are
24:30some of the main targets and two in
24:34tentative is a triple kinase inhibitor.
24:37There were two studies that were the
24:39culmination of multiple other prior studies,
24:41both published in the New England Journal
24:44of Medicine in 2014 and leading to the
24:46approval of these medications for IPF,
24:48and they showed fairly similar findings
24:50for each drug in the IPF population.
24:52These were patients with moderate disease
24:54and what you can see I think that B
24:57is probably the best one to look at,
24:59in that what you see is that
25:01as compared with placebo,
25:03the patients who got prophetic
25:04don't in this particular case
25:06their lung function went down.
25:08What what is important also to note is
25:10that there are lung function did go
25:12down just less than in the patient,
25:15but let's see.
25:16Oh,
25:16and in a you can see the combine
25:18endpoint of FPC or death.
25:20There was definitely a significant
25:22difference over a years time.
25:24This trial will get intended.
25:26It was published at the same time
25:28and shows essentially very similar
25:29findings that curves look very similar.
25:31The graphs look very similar
25:33and essentially shows a slowing
25:34of decline in log.
25:37Other findings that were important
25:38in these studies was there.
25:40These were secondary outcomes,
25:41but and so they can be taken a
25:43little bit with a grain of salt,
25:45but certainly something to
25:46think about that there
25:47may have been an improvement and
25:49progression free survival with profound it.
25:51Own an improvement to time to 1st
25:53exacerbation with a tentative finger
25:54was also important to recognize is that
25:57there was really no change in dismay or
25:59quality of life with either of these.
26:03Overtime there have been pooled data
26:05suggesting that there may actually
26:06be survival data and prevent it own,
26:08which has been the drug that's been
26:10along around a little longer answer.
26:13There are more studies and open label trials,
26:15but essentially if you're comparing,
26:17for example the green curve
26:18versus the blue curve,
26:19you can see that as overtime
26:21there's an improved survival when
26:23pulling data with these drugs,
26:24and this is what we would hope
26:26is that not only the year study
26:29that these drugs were looked at,
26:31but that year over year.
26:32You might actually slow down the
26:34decline stabilized log function to
26:36some degree and improved survival.
26:38We know that within a tentative there's
26:40not quite as much survival data,
26:42but with extension label studies the
26:44same kind of effect held true overtime
26:46where people who either continued
26:48or initiated than intended if their
26:50lung function went down less than the
26:52people who had been on the placebo.
26:56So I just wanted to kind of go through
26:57some of the practical things about that.
26:59The drugs because this comes up
27:01a fair bit so prevented them.
27:03It is an oral tablet.
27:05It's a three time a day drug.
27:07There you definitely need to
27:09be aware of interactions,
27:10particularly with Cipro,
27:11and also the fact that it's less
27:13effective in smokers and that liver
27:15disease is a significant issue as
27:17a severe renal dysfunction when
27:18you're talking about prescribing,
27:20there is a gradual update rayshon of the
27:22dose and it needs to be taken with food,
27:25and LFT monitoring is definitely important.
27:29Side effects tend to be mainly
27:30GI and kind of overall weight
27:32loss and kind of nauseous,
27:34nauseous a little bit of diarrhea.
27:36Sometimes kind of bloating and just
27:38people tend to waste away and so you
27:41would need to really be careful,
27:42especially in older populations
27:44about monitoring weightings,
27:45patients and think about sun sensitivity,
27:47which will talk about.
27:49So in terms of the GI management strategies,
27:52it really helps the patients take
27:54this with food you can you can take
27:56it with the Mail or just after you
27:59can divide the dose across the meal.
28:01Sometimes people require dose
28:03reduction and sometimes you can
28:05manage things by adjusting based on
28:07the kind of meals that people have.
28:09Occasionally you need to do treatment
28:11interruption an you can do a slower
28:14update reaction to help people tolerate
28:16it and sometimes the PPI can be helpful.
28:19The skin can be a major issue,
28:21and so it's definitely worth
28:22counseling patients,
28:23especially if you have a snowbirds
28:24as somebody who spends a lot of
28:26time in Florida in the sun,
28:27travels less of an issue these days,
28:29but hopefully that will become
28:30an issue again,
28:30it definitely can be a major issue
28:32and can be a phototoxic like burn.
28:34It can be minor or can be severe,
28:36and you really need to warn people about it.
28:39Strategies to avoid this or basically
28:41continuing to remind people about
28:43sun exposure and really talked
28:44to them upfront about
28:46it. If you're going to apply if you're
28:48going to prescribe the drug and talk
28:50to them about sunblock, clothing,
28:52exposure, and avoiding sun, even in
28:53direct sun so that such as through glass,
28:56glass and in older people who you're
28:58telling to avoid sun extensively,
29:00you might consider monitoring
29:01their vitamin D levels,
29:02but there's no data on this.
29:05If a rash is severe,
29:07depending on the severity,
29:08you can dose reduce or stop the
29:10drug and there may be topical
29:12therapies that may be necessary.
29:13You may need to get derm involved.
29:16You do want to try to distinguish
29:17from an allergic reaction,
29:19because that's going to really affect
29:21your management as to whether the drug
29:23can be retried and often photos may
29:25be helpful for future derm assessment.
29:29Just working out and intended in terms
29:31of practical issues, it's also a pill.
29:33It's a twice a day drawing
29:35instead of three times a day.
29:37Again, there are interactions
29:38we need to be aware of,
29:40and it's less effective in smokers.
29:42This is not necessarily reduced in in
29:44renal impairment, except for in severe.
29:46It's not really been studied,
29:48and it can also it.
29:49Also,
29:49it can be hepatotoxic probably a little
29:52bit more so than the prevented Onan
29:54LFTS definitely need to be monitored,
29:56and if there's underlying liver disease at.
29:58Needs to be assessed further.
30:00Major issue with an in tentative
30:02is diarrhea to the point where in
30:04the early studies where this was
30:06not recognized there was a huge
30:08amount of drop out from the studies
30:10and so a protocol was developed
30:12where people essentially at the
30:14very first sign of any diarrhea.
30:16You start with hydration an anti
30:18diarrheal medication and generally
30:19speaking in the trials if that
30:21this protocol was followed,
30:22the dropout rate was about 5%.
30:24After this was implemented,
30:25so many patients really can tolerate
30:27it so they read online that the
30:29diarrhea is a horrible side effect,
30:31but in fact many people.
30:33Be managed and dose reduction can
30:35be considered taking a break.
30:37It's often more common in the
30:38in the early part of therapy,
30:40and so if they can make it for that,
30:43sometimes it's better,
30:44but it is something still worth
30:46potentially trying and managing
30:47other GI issues should be considered,
30:49and particularly around the time
30:51of abdominals surgery.
30:52I tend to stop the drug because
30:54there are more
30:55risks for perfect reported.
30:58Other things to be aware of are the risk,
31:01potentially for both robotic and
31:03bleeding complications is probably
31:05related to the platelet derived growth
31:07factor receptor activity there were.
31:09There was some signal about cardiovascular
31:12events and so generally what I will do
31:15is avoid if there's been recent stent
31:17MI or stroke or anything thrombotic,
31:19and then in the trials antika
31:22regulation meaning warfrin and
31:23doacs that not necessarily plastics
31:25were not allowed in the trials.
31:28The labeling of the drug essentially
31:30tells you to weigh the risk benefit,
31:32but in general I tend to avoid in the
31:35calculation and less helpfully counsel,
31:37because there have been
31:39bleeding complications.
31:40So the two of them,
31:41as I mentioned, both FDA approved,
31:43they do have to go through
31:45specialty pharmacies at the VA.
31:47It is covered through the bank
31:49and go directly through there.
31:51They are extremely expensive,
31:52so there they tend to be limited and
31:54the drug companies have foundations
31:56and support so the patients need
31:58to apply through paperwork or
32:00outpatient pharmacy has been
32:01helpful in working with us on this,
32:03but you also need to go through the company
32:06to see if some of the Co pays can be covered.
32:10There's no specific data that
32:12one is better than the other,
32:13and generally in prescribing,
32:15maybe you want to think about side
32:17effects and risk profile to in
32:18terms of their morbid medication,
32:20like their comorbid diseases
32:21in their medications.
32:22You want to be really clear with
32:24patients about expectation management,
32:26so I think it's really important
32:28for people to know that they may
32:30still get worse while on the drug,
32:32but that it is still potentially
32:34less of a progression than they
32:36may have had without it,
32:37but that it is difficult to
32:39know once they are on the drug.
32:41Whether it is working,
32:42because if they progress it doesn't
32:44mean that drug is not working,
32:46but they should not expect
32:47improvement and they should not
32:49expect complete stabilization.
32:50And so I think it's also important
32:52to talk with people about risk,
32:54benefit and how much it's worth it for them,
32:56particularly in in somebody very old
32:58and with a lot of comorbidities as
33:00to whether it's definitely worth it.
33:03I just want to briefly mention
33:05some other indications,
33:06so recently the census trial for
33:08Scleroderma showed similar findings
33:10in terms of slowing progression
33:12in lung function and also the
33:14inbuild trial that was published
33:15in 2019 with progressive fibrotic
33:17interstitial lung disease and
33:18similarly showed slowing of progression.
33:20Both of these words intended there
33:22have been in our ongoing studies,
33:24and I'm not going to go through
33:27these in detail,
33:28but just to let you know that
33:30other connective tissue disease,
33:32lung disease looked at with.
33:34Kind of an with presented
33:35down probably prevented him.
33:37Does work,
33:38but some of the structures of
33:40studies have not allowed it
33:42to show it as well in trials,
33:44and so to sum up,
33:46presented in that area are
33:48approved for IPF in tentative
33:50is approved for IPF as well as
33:53Scleroderma and progressive,
33:54fibrotic interstitial lung disease.
33:55Hopefully prevented, own May get
33:57approved in the future, but not now.
34:00And there's additional studies you want
34:02to think about the side effects that
34:05concomitant medications and conditions.
34:07And you really want to counsel
34:08patients about the pros and cons,
34:10expectations, and really trying to
34:12address side effects as recommended.
34:14I'll stop there.
34:17Thank you very much.
34:18So one question I just had is do
34:20you have any advice aside from the
34:22side effects in the interactions?
34:24Any thoughts about how people
34:26should manage it at patients are
34:28admitted to a hospital or other care
34:30environments. Yeah,
34:31so I think it depends on what's going on.
34:34So if there if there is something that
34:36seems like it's going to be surgical.
34:38If there's anything that involves
34:40anticoagulation or if there's you know,
34:42clotting, bleeding issues,
34:43particularly within tentative,
34:44I would hold that drug.
34:45Similarly, if they're going to.
34:47If it's going to be if they're
34:49not going to be eating regularly,
34:51if they're not going to be able
34:53to tolerate the GI side effects,
34:55I think it is absolutely reasonable
34:56to hold the drug during that time.
34:58I don't, I don't think it.
35:00I don't think that it would
35:02make a major difference.
35:03Certainly during the studies,
35:04people were allowed to hold
35:06drug for periods of time,
35:07and I think about these drugs
35:09as being effective over months
35:10to years rather than immediately
35:12in terms of what you're getting
35:13out of them and what the long
35:15term expectation should be.
35:18OK, great, thank you very much and I
35:20see a question from Shark Ocean.
35:22I just answered that in terms
35:24of off label prophetic home.
35:25It is completely unaffordable.
35:26These drugs are $90,000 a year
35:28and nobody will pay for it.
35:30So it's unfortunately just not an option.
35:32So I wish I could and some people
35:34because I do actually think that in some
35:36cases if they can't have an incentive,
35:38it might be ideal, but I just can't.
35:43Yeah. Thank you both. Alright,
35:46next is Doctor Jonathan Kowskis talking
35:49about the approach to chest tubes and TPA.
35:59Good afternoon, I
36:00appreciate the opportunity to talk.
36:03I'm mostly going to be talking
36:05about what to do on the weekends.
36:11Because we put a lot of chest
36:13tubes in during the week and then
36:15a lot of times it see you on the
36:19weekend as consultants who may
36:21be managing some of those tubes.
36:25Very commonly plural disease
36:28affects many people.
36:32200,000 plus stores in TC's a million
36:35chest tubes for various indications
36:37and I won't go over all that,
36:39but basically what we're dealing
36:41with when we put in a tube,
36:44is this flocculated plurals space and
36:46I show this picture because this is
36:50the ultrasound that you will frequently
36:52be getting for these patients.
36:55The diaphragm, liver or spleen,
36:57and then here you can see a locul,
37:01yated pleural space.
37:05This is what it looks like actually.
37:08Thoracoscopic Lee alot of times so
37:10if we were to break those adhesions
37:14this is what we're seeing when we're
37:17inside the pleural space and this
37:20is what we're trying to accomplish.
37:23Breaking down these adhesions by
37:25putting in TPA and or DNS for
37:28either complicated effusions.
37:30Whatever the etiology is,
37:32this was a malignant effusion.
37:35This is Frank Plus.
37:36We're not going to be able to treat
37:39that very well with just a chest tube.
37:42Alot of these patients with Frank
37:44possible undergo decortication.
37:46But just some key points.
37:49We do use ultrasound to place the
37:52tubes and to do thoracentesis we
37:55recommend it routinely here and I
37:59think all the fellows are well aware of that.
38:03It decreases bleeding and decreases
38:06pneumothorax and decreases complications
38:08associated with thoracentesis.
38:09So please always use ultrasound
38:12when guiding your thoreson TCX,
38:14but here we almost always will
38:18place chest tubes.
38:19By using a Selinger technique,
38:22it's a it's a pretty savvy system.
38:26Basically, a needle lidocaine,
38:28a guidewire, just like a central line,
38:31a couple dilations and the
38:33chest tube can go in.
38:35A lot of times will put in small board
38:40test tubes, maybe 14 French or so,
38:43although on occasion it's larger.
38:46The data behind efficacy when
38:48it comes to parapneumonic,
38:50Effusion's and MPI.
38:52IMA really had to do with the mist two trial,
38:57so almost a decade ago now where
39:00they looked at different treatment
39:02algorithms for instilling lyrics.
39:05Through chest tube,
39:07streptokinase and previously failed,
39:09but in this study they showed
39:12that a combination of TPA and DNS
39:15improve the drainage of infected
39:18pleural spaces and reduce the need
39:21for surgery and so that's why.
39:24We typically will use this as the
39:26frontline approach in patients,
39:27and it's what are thoracic
39:29surgeons like to do?
39:30It's like it's what we want to do,
39:32but it tends to be the in this study.
39:35It was twice a day for three days,
39:37which if we could then avoid putting
39:39it on the weekends we could.
39:41But of course we get Konsult on
39:43Friday for the chest tubes and
39:45then pain management,
39:46and so there's no way around it.
39:51Also, infected tunneled pleural catheters
39:53or indwelling pleural catheters may come in.
39:56You may have a floor X in place that needs.
40:00Rained over the weekend and so I just
40:03want to show a couple of the things
40:06that you may find handy for real time
40:10management of these on the weekend,
40:12one is simply the orders.
40:14If you type in interpleural,
40:16you'll be able to select in epic
40:19that EPA DNA's administration
40:20the dosing is already there.
40:23It goes right to pharmacy.
40:25Pharmacy will prepare it and
40:27send it up to the floor, and so.
40:30It's a lot easier than it used to be
40:35when we had earlier called pharmacy
40:38a couple times a day for billing.
40:41If you just type in PRN still,
40:44or if somehow you remember the codes,
40:47but basically you Bill.
40:48For if I bring a lot fibrinolysis just
40:52like you would any other procedure.
40:55If you're building a thoracentesis
40:57with ultrasound, that code is 3,
41:00two, 555 and so.
41:02You know there's of course important
41:05to build appropriately.
41:07I'm gonna skip this.
41:09This is simply a video that that
41:12shows what to do with them.
41:15The three way stopcocks and.
41:21I think it's probably you're all
41:23smart enough to to figure that out,
41:25so I'm going to skip that part,
41:28but basically show pictures for
41:30the last two or three minutes.
41:32If this is your chest tube
41:34going to the patient,
41:36and we have a 3 way stopcock
41:38on the chest tube,
41:40it it'll drain eventually through
41:42the tube to the pleura vac.
41:44So this is going to the patient.
41:46This is going to the tube and in between.
41:50Here is the apparatus.
41:51With a 3 way stopcock to Simply
41:54put in the TPA or to put in DNS,
41:57there's no order.
41:58You can put 'em in in either order you want,
42:02but they're both going in at the same time.
42:05Basically,
42:06turn the stopcock off towards the pleura vac.
42:09I said this will go off this way.
42:13Inject your medicine.
42:15It'll go into the tube and then you can
42:20leave it off to dwell for an hour or two.
42:24Usually the nurses can undo this,
42:27but I always just double check
42:31because sometimes they forget and
42:33sometimes things just get messed up,
42:36but it's pretty rare, but.
42:40Just check after an hour or two that
42:44they've indeed put this back in the
42:47appropriate position so that then the
42:50drainage can come out of the chest tube,
42:54into the pleura back.
42:56You usually do get increased
42:58drainage no matter what you use.
43:01TPA tends to cause the
43:04production of pleural fluid.
43:06I could label this slide tips by GAIL.
43:09GAIL sent me a little text that said,
43:12you know,
43:13make sure tell everybody a couple things.
43:15One is so this is actually a
43:17chest tube going to patient.
43:19This is the connector
43:21tubing to the pleura vac.
43:22But if you don't have a 3 way stopcock,
43:26basically what you'll be doing
43:28is putting the clamp the
43:30blue clamp on the tube.
43:32And instilling your TPA or Dnas
43:36through a needle into the chest tube.
43:40If you use a 14 gauge or blunt,
43:43needle goes in quite effectively as
43:46opposed to the real tiny gauge needles.
43:48They put a large bore needle into the tube.
43:52The medicine will go into the patient.
43:55This stays clamped for an hour or
43:58two and then again after that you
44:00can unclamp it and the drainage
44:03will ensue into the pleura back,
44:06so you're not actually doing
44:08anything to the chest tube.
44:10And with Clorex is you're not doing
44:13anything with actual pleural catheter.
44:16Everything is through this
44:18connection tubing which goes
44:19basically to the pleura back.
44:24With tunnel pleural catheters or
44:27indwelling pleural catheters,
44:29there's a specific.
44:33A method to connect these to the
44:36pleura vex it's all on them.
44:39I put this in the interventional
44:42pulmonary section in the master file on
44:45box and so you can always refer to that.
44:49But basically you're using a male adapter
44:52into the indwelling pleural catheter.
44:54It goes in and clicks once
44:57it clicks on the other end.
44:59You can put your 3 way stopcock.
45:03And a football adapter.
45:05This adapter that is what allows you
45:09to set it up to the chest tubing.
45:12You clean the tubing,
45:14cut it here and the adapter will
45:17will fit in and then you have a nice
45:20three way mechanism for instilling
45:23whatever agent into the player X.
45:28If if that's what you need, so again we can.
45:31We can easily talk you through this.
45:34It's it's really difficult to talk
45:36about these things in a PowerPoint and
45:39expect you to know it, but trust me,
45:41in and it takes 2 minutes or so,
45:44and it's relatively easy and.
45:47Basically,
45:47the gist is that if we have a player acts in,
45:51we're connecting it,
45:52putting in a 3 way adapter and
45:55then connecting it to the to the
45:58pleura vac overall.
46:00The nurses should know that the
46:02suction is actually we should know
46:04that the sections regulated by
46:06how much water is in this Chamber,
46:08so it's up to minus 20 where it's bubbling.
46:11It doesn't matter as much what
46:14the wall pressure is,
46:15although we put it on moderate
46:18most of the time.
46:20So we can walk you through it on
46:23FaceTime or however is needed,
46:26but we basically put in TPA and
46:28Dnas for Empyema's and parent Monica
46:31Fusions TPA for clogged pleural catheters.
46:34You can bill it.
46:38By putting PR and still an epic and
46:40you can order the Medecins by going
46:42into the interpleural analytic space.
46:44And that's all I have,
46:46but I'm happy to show you videos or talk
46:49you through it at any point in time.
46:55Thanks, Jonathan, very helpful.
46:57Hopefully we'll be sending
46:59fewer people to surgery.
47:01So next is Doctor Carla Rochester talked
47:04about to work on COPD Re admissions
47:07causes and how to prevent them. Hi
47:09everybody, just give me one
47:11second to share my screen.
47:15You gotta just switch this to the.
47:18Slideshow format everybody see that.
47:23Can you see it? Yeah, OK great so. Yes.
47:30Super so thank you for the opportunity
47:32to give a little burst presentation.
47:35Today I've been working as Jonathan said
47:37for quite some time on what is known
47:40as the Yale New Haven Health System.
47:43CEO PD re admissions reduction Initiative
47:45and I want to tell you a little bit of
47:49background about that and some of the
47:51activities of our group because there's
47:54a lot that's evolving and going to be,
47:57you know, inactive.
47:59Clinical workflow in the near future,
48:01and I want the pulmonary
48:03team to know about it.
48:05OK, sorry um hang on have to get.
48:08My slides are.
48:10Here we go.
48:14OK, so as
48:15everyone knows, COPD exacerbations are
48:18associated with morbidity mortality
48:20as well as health care costs and the
48:23overall RE 30 Day re admission rate in
48:26the United States ranges from 17 to 30%.
48:30Notably, about 1/5 of United States
48:32Medicare beneficiaries are re admitted
48:34within 30 days of their hospital discharge,
48:38with an annual cost of estimated
48:41more than $15 billion.
48:43As also probably well recall since 2009,
48:46as part of the Affordable Care Act,
48:49the 30 Day re.
48:51Admission rates for congestive heart failure,
48:53pneumonia, myocardial infarction,
48:55an later see OPD added as well,
48:58were publicly reported
48:59as quality performance.
49:01Measures and starting in 2000
49:03fiscal year 2015,
49:05Medicare's EMS began penalising
49:08hospitals by decreasing reimbursements
49:10to those hospitals with high
49:13unplanned readmission rates.
49:15There are many factors that are known
49:18to be associated with increased
49:20risk of hospital re admission
49:22amongst people with COPD.
49:24There have been several studies that
49:26have sussed this out and it is clear that
49:30there exist patient related factors,
49:32provider related factors and
49:33health system related factors.
49:35An example of patient factors would be
49:38those with more severe underlying disease.
49:40Those who require supplemental oxygen.
49:42Those of older age or who have.
49:45Evidence of respiratory muscle overload
49:48on going at the time of discharge.
49:52Lower socioeconomic status.
49:54Comorbidities, low functional level,
49:56low physical activity, etc.
49:58Provider factors include the.
50:01Impact of the different medications
50:02that are provided to the patient,
50:05whether or not they have oral cortico,
50:08steroids or antibiotics on discharge.
50:10Health system factors include the
50:12length of stay as well as whether
50:15they get follow up following discharge
50:18and suboptimal transitions of care.
50:20There are many other very major
50:22and important contributors to re
50:24admissions that need to be mentioned.
50:27The first is that COPD is grossly
50:29underdiagnosed so many patients who
50:31are hospitalized with COPD have never
50:33known that they had the diagnosis prior
50:36to that hospitalization and some of
50:39them even present with Ventilla Tori
50:41failure at time of 1st diagnosis.
50:43It's also true that many practitioners
50:45do not adhere to evidence based
50:47treatment guidelines,
50:49not adherence by patients to a
50:51prescribed medical treatment is
50:53a major problem as well.
50:55Pulmonary rehabilitation is
50:56grossly underutilized.
50:57Patients report barriers to physical
50:59activity and things such as self
51:01management programs which can be
51:03helpful to help patients identify
51:05when exacerbations are coming on and
51:08therefore can partner with health
51:10care providers to treat them early.
51:13The role of those management programs
51:15is controversial because there have
51:18been increased mortality signals
51:20in at least one study.
51:22To add to the problem,
51:24see OPD is often grossly misdiagnosed.
51:26That is to say,
51:27chart diagnosis that are perpetuated
51:29through the system are often incorrect.
51:32Many things masquerade as COPD
51:34exact CCOPD or COPD exacerbation,
51:36and this is particularly problematic
51:38in underserved patient populations.
51:39I would mention misdiagnosis of COPD
51:41is often associated with obesity and
51:44cardiac disease, and as you all know,
51:47hospital re admissions result from
51:49a myriad of things other than just
51:52see OPD exacerbation.
51:53So based on a study that genpo sick
51:56and I did in conjunction with the Yale
51:59MPH student a couple of years ago,
52:02we learned that many of these important
52:05issues are very true at our own institution,
52:08be it as a wonderful institution as it is.
52:12For example, we evaluated
52:14a / a one year period.
52:16All the patients who were admitted to Yale,
52:19New Haven Hospital, York Street,
52:21and St Rayfield's with the suspected
52:24diagnosis of COPD exacerbation.
52:25Who had at least one re admission in
52:2830 days over that one year period
52:31and as examples of opportunities
52:33for a quality improvement,
52:3580% of those individuals had no
52:37documented PFT to confirm the diagnosis
52:40ever in their medical record,
52:42and of the 20% who did have a PFT,
52:45only 80% had airflow obstruction
52:47to confirm the diagnosis.
52:49None of the current smokers with
52:51those conditions were referred
52:53to tobacco treatment program,
52:54and only two patients were referred to
52:57pulmonary rehab. So these are examples.
52:59Of of ways in which our institution can
53:03benefit from some focused attention
53:06on evidence based and increasing
53:09consistency of care for these individuals.
53:13So we set out to establish a CEO
53:16PD working group and it was a
53:20multidisciplinary working group that
53:22met regularly over the course of a
53:26couple of years period of time to
53:29really evaluate the different types
53:32of issues that where there were
53:35opportunities for improvements in
53:37quality of care an in fiscal year 2019,
53:41our group was formalized.
53:43Into a Yale New Haven health system.
53:46CEO PD re admissions performance
53:49Improvement team we had sponsorship
53:51from the health system quote from the
53:54quality improvement and safety division.
53:57We had a project facilitator and
53:59that with recognition that SEAL PD
54:02patients receive their care from
54:04multiple providers and individuals
54:06across several different venues,
54:08home outpatient clinics,
54:10eadies inpatient care sniffs,
54:12extended care facilities and back to home.
54:15As well as,
54:16given that there are many opportunities to
54:19improve handoffs and transitions of care,
54:22we developed subcommittees to tackle
54:24care processes relating to the different
54:27points of care in patients management.
54:30The leadership with this we
54:32developed different actions that
54:34were implemented at that time,
54:36in particular under the leadership of
54:39Chemia Conde from the hospital esteem Ann
54:42Caroline Gillespie and Care Management.
54:44There was a transitions of care
54:47management program development that
54:49implemented post discharge phone calls
54:51and addressed a variety of issues
54:54including ability to get medications,
54:56transportation to and from appointments,
54:58behavioral, social,
54:59caregiver related issues.
55:00Pulmonary rehab referrals and many others.
55:03And this was a very successful
55:05intervention that actually did reduce re
55:07admissions during the time it was active.
55:09We also developed a discharge order
55:11set which I'll mention more in
55:14a minute and during that year we
55:16developed content for an evidence
55:18based comprehensive approach to
55:19the care of inpatients with COPD
55:21which is now being implemented as a
55:24formal care pathway,
55:25which I'll mention also in a moment.
55:28This just gives you a
55:30screenshot of the LPD discharge
55:32order set in Epic that we developed.
55:35Again, see OPD patients are
55:37not receiving evidence based
55:39recommendations often at discharge.
55:40So our re admissions team,
55:42which by the way initially was
55:44focused around Yeldon Haven Hospital,
55:46an Greenwich Hospital.
55:48Our performance improvement team
55:49identified opportunities to enhance
55:51the discharge process and we
55:53created a discharge order set that
55:55would allow for quick decision,
55:57support and selection of things to be.
56:00Um, undertaken at the time of discharge
56:02with the hope of improving transitions
56:05of care back to the outpatient setting,
56:08and you can browse this on your own,
56:11but that includes general
56:12discharge instructions,
56:13plus medications,
56:14including an evidence based stepwise
56:16approach to adjustments to be made to
56:19have medications following exacerbation
56:20as supported by guideline based prompts.
56:23We have COPD specific DME we have
56:26relevant referrals and the like so this
56:29is something you can browse through further.
56:32Where we are now is that we had a
56:35bit of a hiatus or slowing of our
56:38activities between March and early
56:39fall of 2020 during the pandemic,
56:42but we resumed in earnest during
56:44the fall of 2020 and our ongoing
56:46process now is that COPD is again
56:48been designated as Yale.
56:50New Haven health system corporate
56:52objective for fiscal year 2021.
56:54We now have a new administrative
56:56structure in the health system that
56:58will allow the processes to be
57:00expanded to all the Yale New Haven
57:03health systems delivery networks.
57:04So there are system champions Jeanette
57:06Bogdan and Steve Choi from the Office
57:09of Quality Improvement in Safety.
57:11There are systems stakeholders who
57:13include the direct Executive Director for
57:15Quality and Safety as well as Deborah Rhodes,
57:17who is the director of the new Office for the
57:20Something called The Care Signature Pathway,
57:23which I'll mention in a second.
57:25We have individual delivery network sponsors,
57:27so at Yale New Haven Hospital we
57:30have sponsors and at each of the
57:32other delivery networks, Greenwich,
57:34Bridgeport, Lawrence Memorial,
57:35etc.
57:35Each of these types of team
57:38silos are developing and within
57:40the Young Haven Hospital,
57:42our project leads are Adam Ackman,
57:44Anne Margot, Minacci.
57:46Oh,
57:46we have project managers and our CEO PD
57:50working Group that's been working for
57:52some time are developing the content
57:55for and leading the the sort of content
57:58related stakeholder activities in this group.
58:01The Care signature program,
58:02under the leadership of Deborah Rhodes
58:05and with implementation from Nancy Kim,
58:08who's one of the hospitalists.
58:10Is widespread throughout the health system.
58:12It's not just related to COPD.
58:15There are many care pathways
58:17that are being developed,
58:18but the idea is that these care pathways
58:21that will be developed will implement
58:23evidence based care across the health system.
58:26They will then enable embedding
58:28of evidence based practices and
58:29consensus into clinical workflow.
58:31They will enable building of
58:33clinical pathways to guide clinical
58:35patient management,
58:36real time data,
58:37replicate integrated into epic using
58:39something called the Agile software system.
58:41And they will evaluate and
58:43address issues related to quality,
58:45safety,
58:45access equity and cost.
58:47And just to finish up.
58:49I will show you just a couple of
58:51screenshots of the inpatient SLP
58:53care pathway that Nancy Kim and
58:56I have been building based on the
58:58inpatient process of care content
59:01we had developed in the past,
59:03and basically what you could see is this
59:05is a stepwise care pathway approach
59:08where there are different boxes.
59:10This, by the way,
59:12is still under development.
59:13It all doesn't fit on one single slide,
59:16so I'm showing you screenshots and this is
59:19also not the very final way it will appear.
59:22It's still under under development,
59:24but the general idea is that within
59:26each of these stepwise buttons we will
59:28begin the pathway for patients admitted
59:30with suspected COPD&COPD exacerbation.
59:32There, the first step will be trying to
59:35confirm whether the diagnosis of COPD
59:37is correct and or truly established
59:39with processes for what to do.
59:41If there is no clear.
59:43Establish diagnosis other
59:45diagnosis to consider,
59:46and then a stepwise approach for
59:49those where COPD&COPD exacerbation is
59:51confirmed and there will be opportunities
59:54to implement higher levels of care.
59:56A stepwise approach to that there will be.
01:00:00Planning around whether the patient is
01:00:03or isn't improving and there's discharge
01:00:05planning and and a stepwise approach
01:00:07to a multidisciplinary assessment.
01:00:09While the patients in inpatient
01:00:12from the point of view of the MD,
01:00:15the patient see OPD diagnosis
01:00:17there exacerbation their triggers,
01:00:18their comorbidities from the
01:00:20functional status perspective,
01:00:21from physical therapy from the
01:00:23respiratory therapy perspective,
01:00:24and their oxygen needs, their CME,
01:00:27their DME needs from the education
01:00:29perspective,
01:00:29and nursing perspective.
01:00:31And then discharge planning,
01:00:32care management and so on.
01:00:34And so these care pathway.
01:00:35Each of these bullets in the care
01:00:37pathway is going to have action items,
01:00:40links to order sets,
01:00:41Evidencebased prompts and it'll
01:00:42be very user friendly.
01:00:43We hope and the care pathway for
01:00:46the physicians and aips is to be
01:00:48complemented by dot phrases that we are
01:00:50developing with so called todo lists.
01:00:52If you will,
01:00:53or reminders or prompts for things to do
01:00:55during the hospital stay for the other,
01:00:58Revel relevant disciplines.
01:00:59RT nursing social work, care management,
01:01:01etc.
01:01:01So this is all I wanted to present
01:01:04to you today.
01:01:05The hospitalists and how staff
01:01:06and other you know inpatient
01:01:08providers will be using this care
01:01:10pathway in the near future.
01:01:11It's expected to roll out soon,
01:01:13so stay tuned.
01:01:14We're going live soon,
01:01:15and perhaps Nancy Kim can come and give a
01:01:18live demo of it when we've got it finalized,
01:01:21perhaps at a
01:01:22future meeting. Thank you. Thank
01:01:24you Carla. Yeah lot of the
01:01:26pathways are going live.
01:01:28It'll be pretty exciting
01:01:29when those those go out.
01:01:31A lot of work.
01:01:32OK, next is a doctor,
01:01:34Inderjit Singh talking about
01:01:36indication use for the shape.
01:01:38Cardio pulmonary exercise
01:01:40testing equipment. Hindi
01:01:42yeah I'm here. Share my screen now.
01:01:58Alright, I'm going to talk
01:02:00about Submaximal exercise.
01:02:01Testing is the test that we perform on
01:02:04all of our patients that come through
01:02:07our plumbing vascular disease clinic.
01:02:10An it's it's diagnosis an it's an it's
01:02:13utility in follow up for these patients.
01:02:16So the you know echoes and Poly
01:02:19function tests are useful adjuncts,
01:02:21but ultimately those are static test wells.
01:02:25The pathologic pathophysiologic hallmark,
01:02:27or Poly vascular disease. Anne.
01:02:30Is characterized by exertional
01:02:33related symptoms of patients
01:02:35complained of exertional dyspnea.
01:02:37Exertional chest pains,
01:02:39exertional syncope, and so,
01:02:41when you subject them to exercise,
01:02:44the dynamic perturbations of the cardio
01:02:47pulmonary unit is is unmasked with exercise
01:02:50testing and in palmy vascular disease.
01:02:54In Parma.
01:02:55Hypertension be whatever the causes you have.
01:02:58This complex interaction between the cardio.
01:03:01Primary and skeletal muscle system,
01:03:03all of which will be analyzed.
01:03:05All all all functions of which
01:03:08will be analyzed using this sub.
01:03:10Maximum exercise testing.
01:03:11And so you can see that you know there are
01:03:15various components of the heart, comma,
01:03:17vascular system and skeletal muscle.
01:03:19Their dysfunctional in pH.
01:03:22And so the step test is a is a.
01:03:26Very handy test who see if
01:03:27I can just do this.
01:03:32It's a it's a, you know.
01:03:33It's a portable test.
01:03:35It comes to the metabolic card and a
01:03:37step which is about 14 centimeters high.
01:03:40The mouthpiece is connected to a
01:03:43gas exchange and analyzer, an we.
01:03:46Initially what we do is we get arresting
01:03:49measurements for about 2 minutes and
01:03:52then we have the patient go up and
01:03:56down the steps for about 3 minutes,
01:03:59during which time we monitor
01:04:01the auction saturation.
01:04:03The oxygen consumption, the exhaled.
01:04:06Carbon dioxide, the end title, CO2 an.
01:04:09We extrapolate other measures like
01:04:11palm nievas capacitance and the
01:04:13oxygen uptake efficiency slope,
01:04:14which I'll talk about later.
01:04:20And so these are the.
01:04:22These are the parameters that
01:04:23we gather during the testing.
01:04:25So we get the Arabic exercise capacity.
01:04:28We get the uptick efficiency slope,
01:04:30which is basically.
01:04:33An submaximal assessment of
01:04:35the oxygen carrying capacity.
01:04:38You get to assess someones
01:04:41ventilatory efficiency.
01:04:42And you also get entitled CO2,
01:04:44which is a mark of polymer blood flow.
01:04:47And then there's this
01:04:49handy marker assessment,
01:04:50which is the palm vastly
01:04:52capacitance which we found to be
01:04:55closely correlated to invasive
01:04:57hemodynamic measurements of
01:04:58Palmi arterial compliance.
01:05:02And I just go through a couple of cases.
01:05:04So this is the first case
01:05:06of a 68 year old female.
01:05:09With no past medical history had
01:05:11worsening dyspnea for the past.
01:05:14Four months, she was referred for exercise
01:05:17pH because she had moderate TR at rest,
01:05:21which which became severe with exercise.
01:05:24And she was a very active individual.
01:05:27She you know, she was an avid hiker so
01:05:29we can look so that the print out the
01:05:32first page of the print out and the last
01:05:35page of the print out is shown here.
01:05:38So the first page to print out it gives
01:05:40you the three main gas exchange variables,
01:05:43so it gives you the breathing efficiency,
01:05:45the resting end title, CO2,
01:05:47which they call the plumber profusion,
01:05:49and the Delta the rest and
01:05:51exercise change in your end title,
01:05:53CO2, which is the change in.
01:05:55Palmer profusion,
01:05:55and you can see in this individual
01:05:58you know the observed,
01:06:00which is measured the normal
01:06:02values and what the risk cutoff
01:06:04value is in this individual.
01:06:07All the all,
01:06:08the gas exchange parameters that would
01:06:10indicate palm leaves a dysfunctional normal.
01:06:13An exercise capacity was 134% predicted,
01:06:15normals about 80% predicted.
01:06:18So just by this testing in itself,
01:06:20I can I I can tell that
01:06:22without a right heart Cath,
01:06:23without invasive tests that
01:06:24this person does not have.
01:06:26Probably ask the disease and
01:06:28she ended up having primary TR.
01:06:30The contrast that this 25 year old who we
01:06:35diagnosed with Capri Hemangioma ptosis.
01:06:39Who had worsening dyspnea,
01:06:41and you can see that the you know
01:06:44breathing efficiency is so abnormal.
01:06:46The change in entitle CO2 is
01:06:49markedly abnormal as well.
01:06:51This right here where the
01:06:53cursor is is following.
01:06:55That's the end title CO2.
01:06:57So normally as you exercise you generate
01:06:59more CO2 and you exhale more CO2.
01:07:02So the normal response is an
01:07:04increment in your end title CO2.
01:07:06So you're changing polymer
01:07:08perfusion should be a positive one,
01:07:10but this individual immediately
01:07:12the onset of exercise.
01:07:13That's a rapid decrement in
01:07:15the in the end title CO2.
01:07:18Suggesting that there is an
01:07:21abnormal polymer blood flow,
01:07:23either from increase in RV
01:07:25afterload and or fairly of cardiac
01:07:29output augmentation exercise.
01:07:31And along with that you see a D
01:07:34saturation from 94% at rest to 89% rest,
01:07:36all of which are hallmarks
01:07:38upon the vast disease.
01:07:39And so when we spawned him he had
01:07:42moderate precapillary disease.
01:07:45Anne. Often when you when you see us.
01:07:50Write the report in our
01:07:52notes about these patients.
01:07:53This is this is usually what we write,
01:07:55so this is the patient I saw this past week.
01:07:58Photopolymer E. On advanced therapy,
01:08:01who's now lined up for a liver?
01:08:05So if you see the 1st,
01:08:06so this is the top part of the first page.
01:08:09You can see that.
01:08:11Where she started off.
01:08:13On a scale where where they scale it
01:08:16to be in her functional status will
01:08:19be severe to near normal and we.
01:08:23I input all the different
01:08:24variables to begin with,
01:08:26so the V in ventilatory efficiency.
01:08:28The change in end title,
01:08:29the auction up.
01:08:30Take the video too,
01:08:31so on so forth and the very end is
01:08:35the problem if asked capacitance.
01:08:38And you can see the baseline
01:08:40measures compared to that in in 2022.
01:08:42That in February on therapy those
01:08:44marked improvement all the different
01:08:46gas exchange variables just by looking
01:08:48at this I knew that her right heart
01:08:50hemodynamics were going to be normal,
01:08:52so we swanda right heart
01:08:54hemodynamics are normal,
01:08:55and now she's set up for liver.
01:08:58And so Phil and I will have this this, this.
01:09:02This table will mention
01:09:04what the medications are on,
01:09:06and then there will be an
01:09:10interpretation right below.
01:09:12If anyone's interested,
01:09:13that is.
01:09:18So so why? Why the sub maxi pad?
01:09:21As fewer safety concerns than the maximum,
01:09:24testing is well tolerated.
01:09:28It's not as time consuming.
01:09:29It's simple and is also proven.
01:09:32So we get a lot of referrals
01:09:35from the cardiology folks.
01:09:37Patients with pH, RV dysfunction,
01:09:39echo evidence of left sided disease,
01:09:42but nonetheless, you know have
01:09:43had pH and right RV dysfunction.
01:09:46And so we decided instead of swanning
01:09:49all these patients and just showing
01:09:51them that the wedge is elevated
01:09:53and is just pure half past versus
01:09:57combined universes combined disease,
01:09:58we decided to see if.
01:10:01If the sub maxi pad is able to distinguish
01:10:04between the two different happy phenotypes,
01:10:06'cause it be very helpful, right?
01:10:07If it's pure half bath,
01:10:09we say look this is all wedge elevation,
01:10:12no PVR.
01:10:14You know it's on your side of the septum.
01:10:17And So what we found was.
01:10:19There was a there was a marked
01:10:22distinction between the two half
01:10:24past Fino Fino types based on all
01:10:26the different gas exchange variables
01:10:28and we found that the measure that
01:10:32that best distinguish between pure
01:10:33half bath and the combined disease
01:10:36was was this Omni vastly capacitance
01:10:38GX cap measure GX cap measure,
01:10:41which is the which has a strong
01:10:44correlation from invasive.
01:10:45He want dynamic polyarticular compliance.
01:10:49You know, and others have shown that
01:10:52it's superior to six minute walk test.
01:10:55In assessing pH severity. Anne.
01:11:00You know our collaborators.
01:11:01Colleagues have shown that it's it's very,
01:11:05very sensitive and somewhat specific
01:11:07in the diagnosis of Scleroderma pH.
01:11:09An others have shown that the change
01:11:13in an end title CO2 during exercise.
01:11:17Correlated well to the
01:11:19peak exercise capacity.
01:11:20Anne Anne was associated with with
01:11:23with a significant mortality.
01:11:25For those who do not augment the end title.
01:11:29CO2 accordingly during exercise.
01:11:34That's all I have here. Cindy,
01:11:36I'm just one quick question.
01:11:37Before we go on for Mark Siegel,
01:11:39how do you think about the role
01:11:41of Level 3 cepet which you and
01:11:43Phillip started in the past
01:11:45couple of months compared to this?
01:11:49Um, so I left out one slide.
01:11:52I should have left it in actually
01:11:55to be there was the study that we,
01:11:59the halfpipe study.
01:12:00There were controls in this study.
01:12:04And the controls were controlled
01:12:06based on peak exercise.
01:12:07Hemodynamics where they where
01:12:09they have a normal cardiac output
01:12:12and normal exercise capacity.
01:12:15Those individuals ended up having
01:12:18preload failure or dysautonomia.
01:12:20On invasive hemodynamics.
01:12:24And if you look at the
01:12:27controls and the isolated.
01:12:29Postcapillary plumbing hypertension.
01:12:31There wasn't a difference between
01:12:33the gas exchange variables,
01:12:36Interestingly enough.
01:12:37What we found was that the echo
01:12:40clearly distinguish the half bath
01:12:42groups from the controls clearly did,
01:12:44but if you take the echo out of the equation,
01:12:48could not distinguish the
01:12:50Postcapillary group from the from
01:12:52the controls which made up was made
01:12:55up mainly of the preload patients.
01:12:58And so.
01:12:58What I'm trying to get is that
01:13:01if you see someone with.
01:13:03Normal echocardiogram and
01:13:05everything else is is unremarkable,
01:13:07but yet you see abnormal gas
01:13:09exchange variables that makes you
01:13:11think you know likely this person
01:13:13has a mitochondrial myopathy where
01:13:15the hyperventilate or preload or
01:13:17dysautonomia where the hyperventilate
01:13:19during submaximal exercise,
01:13:21which we showed in in the
01:13:24most recent paper there so.
01:13:25So that that was set, it set us up.
01:13:29For invasive cardio, comma exercise testing.
01:13:32Unfortunately,
01:13:33for exercise comma hypertension,
01:13:35we looked at it.
01:13:38The sub Maxi pad doesn't really.
01:13:42Show significant abnormalities
01:13:43to suggest exercise bombing,
01:13:45hypertension and that that would mean
01:13:48that the patient will need an invasive CPAP.
01:13:51Anne and one other thing is that
01:13:53you cannot diagnose exercise,
01:13:55comma hypertension by echocardiogram,
01:13:57so that patient earlier at
01:14:00exercise pH by echo.
01:14:01Pressure is the product
01:14:02of resistance and flow.
01:14:04So with exercise,
01:14:05invariably appreciate your
01:14:06flow is going to go up,
01:14:08which will translate to an increase in
01:14:11pressure so you know we diagnose it a lot.
01:14:15Last week we had two patients
01:14:17with exercise pH,
01:14:18so those patients have an abnormal
01:14:20Poly vascular resistance with
01:14:21exercise rather than an abnormal or
01:14:23an increasing flow and exercise,
01:14:25which is to be expected with exercise.
01:14:29Great thanks Cindy.
01:14:30Thanks Mark for the question.
01:14:32So next Doctor Austin Chetra will
01:14:34be talking bout ventilator weaning
01:14:36and chronic respiratory failure
01:14:38and sort of local guidelines.
01:14:42Yeah hi everyone, hopefully
01:14:44you can all see this.
01:14:49So I'm going to be talking about a
01:14:51little bit about the background for
01:14:54weaning in patients on prolonged
01:14:56mechanical ventilation, as well as
01:14:59our current guidelines on 10 seven.
01:15:02So prolonged mechanical ventilation
01:15:04is defined by CMS as patients needing
01:15:07greater than 21 days of mechanical
01:15:10ventilation for at least six hours a day.
01:15:13Um, and they've been studies
01:15:15reporting about up to 13% of all
01:15:19ventilated patients and are requiring
01:15:22prolonged mechanical ventilation.
01:15:23And we all know that that is associated
01:15:27with increased healthcare costs and
01:15:30definitely worse outcomes in the ICU.
01:15:34And ultimate.
01:15:39So what are some of the
01:15:41outcomes for these patients?
01:15:43This is an interesting observation.
01:15:45ULL study it looked at about 1:26 patients
01:15:49and followed them and not surprisingly,
01:15:52only 9% of these patients
01:15:54were alive at one year.
01:15:56But what was most striking was the
01:15:59discordant expectations between
01:16:00family members versus physicians.
01:16:02An just 26% of the family members
01:16:05reported that physicians at discussed
01:16:07what their expectations were.
01:16:09Outpatients.
01:16:10Likelihood for survival,
01:16:12their functional status and quality of life.
01:16:19This is a meta analysis looking at
01:16:22about 39 studies and it looked at
01:16:25mortality amongst other outcomes for
01:16:28patients on prolonged mechanical
01:16:30ventilation and they found about a 60%
01:16:33mortality for these patients in the US.
01:16:36In particular, it was actually higher,
01:16:39with 73% in the US versus non
01:16:42US countries in these studies.
01:16:45And only 19% of these patients
01:16:48were discharged to home and only
01:16:5250% successfully liberated.
01:16:54So with that in mind.
01:16:58You know some of the things that come up
01:17:01are a protocolized approach for winning,
01:17:04and there are many arguments against
01:17:07protocol protocols you know.
01:17:09Is it just too rigid?
01:17:11You know one size doesn't fit all,
01:17:14and definitely while no single protocol
01:17:17can cover each and every patient in the,
01:17:21you know,
01:17:21in a perfect manner the utilization of
01:17:25most protocols do help provide superior care.
01:17:28Two well vast majority of the patients
01:17:31there will always be exceptions,
01:17:32but for most of the patients they will work.
01:17:37This was an interesting study.
01:17:39It it looked at this protocolized
01:17:42approach to actually use respiratory
01:17:45therapy to drive the S PTS.
01:17:48Up completely versus just regular
01:17:52practice and they found.
01:17:54You know that the weaning duration
01:17:57was shorter with patients who
01:18:00would on the RT driven protocols.
01:18:02Um?
01:18:02You know the suggestion from this
01:18:05is really that maybe it's not our
01:18:08approach that matters so much as
01:18:11just putting them on a protocol
01:18:13and following the protocol.
01:18:15There are many other studies describing
01:18:18better outcomes for patients on
01:18:20prolonged mechanical ventilation,
01:18:22just with use of a protocol based therapy.
01:18:27Some of the major winning strategies,
01:18:30as you all know that we use our precious
01:18:33support versus unassisted breathing,
01:18:35using Trach mask and one of the
01:18:38more landmark trials that was
01:18:40published in JAMA in 2013 about this.
01:18:43Looked at patients using pressure
01:18:45support versus just unassisted
01:18:47breathing through a trach mask.
01:18:49Um, it was an interesting study.
01:18:51They initially,
01:18:52for the first 5 days they put
01:18:54all patients on trach masks.
01:18:56Those who did well in those five days were
01:18:59considered liberated and were not randomized.
01:19:02The failure group from within that
01:19:04five days were the ones who were
01:19:07randomized to either the trick mask
01:19:09group or the pressure support group.
01:19:13And they found that trick mass resulted
01:19:16in faster weaning then pressure.
01:19:18Support is about 15 days versus 19 days,
01:19:22and this difference was more marked
01:19:24in the late Failure Group and the
01:19:28Late Failure Group was defined as
01:19:30those who fail that initial five day
01:19:33period on Trach Mask after 12 hours.
01:19:36So you can see the difference
01:19:38was quite marked there and there
01:19:41was no mortality difference or.
01:19:43Out between these two groups.
01:19:48Um, you know how long can we
01:19:50expect to win these people?
01:19:52We have some patients.
01:19:54On 10, seven who've been there for
01:19:57a couple of years and guidelines.
01:20:01Julie suggested unless a
01:20:02patient has respiratory failure.
01:20:04Do you do something that is irreversible
01:20:07like a LS or a C spine injury that
01:20:12you should not consider them as?
01:20:15Permanently ventilator dependent,
01:20:16unless they have failed about
01:20:20three months of weaning.
01:20:22So with that in mind.
01:20:24I worked with many members from
01:20:27respiratory Care and Elaine and Jonathan
01:20:30to come up with these guidelines for
01:20:34use on 10 seven anyone elsewhere.
01:20:37Um, so importantly,
01:20:38this is not a protocol.
01:20:40Currently we these are just
01:20:43guidelines we're hopefully hoping
01:20:45to make it a protocol if we can get
01:20:49the adequate resources behind it.
01:20:51But essentially what it means is
01:20:53that every patient on 10 seven
01:20:56will be evaluated daily by the
01:20:59respiratory therapist in the team.
01:21:00As long as there,
01:21:02on minimal Fio two peep and
01:21:05are otherwise stable.
01:21:07And don't meet any of these
01:21:09exclusion criteria,
01:21:10which are fairly straightforward,
01:21:12as none of them should really be on 10.
01:21:16Seven they should be hemodynamically stable.
01:21:19Um,
01:21:19you know they shouldn't have
01:21:22something active going on like
01:21:25a hemorrhage or increase ICP.
01:21:28I mean they shouldn't have a known
01:21:30history of bilateral diaphragmatic paralysis.
01:21:32Our profound neurological deficits.
01:21:35They would all go onto a daily SPT.
01:21:40The SBT for these patients would
01:21:43be similar as in 505 or 00.
01:21:47Or treat mass currently just cause of.
01:21:51Covid rules and regulations.
01:21:53We're sort of sticking with the 5:05.
01:21:55Was it over 0 on 10 seven?
01:21:58Anne Anne in our usual sort of make
01:22:02you weigh the failure criteria are
01:22:05pretty much the same as SPD in the ICU,
01:22:09which is a risk.
01:22:11Be more than 120 takip NIA hypoxemia,
01:22:14just obvious respiratory distress or
01:22:17hemodynamic instability during SVT.
01:22:19If any of that happens then they are
01:22:23considered to be to to have failed.
01:22:29So if they do not fail,
01:22:31they should all be placed
01:22:32on a trach mask. This will.
01:22:35This would be our first choice.
01:22:38And trig mass would be up
01:22:39to 12 hours as tolerated.
01:22:44And then let me let me
01:22:46reach out to
01:22:46see if we can schedule an appointment.
01:22:49Um, so up to 12 hours as tolerated and
01:22:52then you can rest them on either volume,
01:22:55AC or pressure support at night.
01:22:58That would be day.
01:22:59One day two you would do the
01:23:02same thing up to 12 hours.
01:23:04Rest them on the vent at night.
01:23:08And then day three you would go on
01:23:10to up to 24 hours or as tolerated of
01:23:13Trick Mask an if they finish that day.
01:23:15Three of 24 hours then you would
01:23:18just let them be on trach mask.
01:23:21If these patients fail with the
01:23:23any of these failure criteria,
01:23:26you the physician has the option of either
01:23:29putting them back on the ventilator,
01:23:32resting settings,
01:23:33or they could also just put them
01:23:36on a pressure support winning arm.
01:23:38This is not preferred,
01:23:41just going by what we know.
01:23:44About winning for these patients.
01:23:46And so the pressure support trial
01:23:48would be that the respiratory
01:23:50therapist would then increase their
01:23:52pressure support to a level where
01:23:54the patient is comfortable and they
01:23:56would be able to win the pressure
01:23:59by two centimeters every six hours.
01:24:01Now, because this is not a protocol,
01:24:03this weaning needs to be done
01:24:05by the provider,
01:24:07so in every six hours if they're doing OK.
01:24:10For example, if you start off with.
01:24:1315 / 7 and they are OK for six hours.
01:24:17Then the hospitalist or the APP or U as
01:24:22a consultant can ask them to go to 13.
01:24:26So that would be by two centimeters.
01:24:28If they do OK for six hours,
01:24:30they can go down by more,
01:24:32but for every change that you want done,
01:24:34you need to make the order.
01:24:36You need to change the order.
01:24:38Anarti won't be able to do
01:24:40this without an order.
01:24:42You can then rest them on their resting
01:24:44settings or continue on pressure
01:24:46support if you think they're doing OK,
01:24:48you can do it, you know,
01:24:50up to 12 hours, similar to trach mask,
01:24:52and then rest them and then date
01:24:54to the same process would start.
01:24:59So just to summarize,
01:25:00some of the important things we know also
01:25:03from other studies at once a day as BT.
01:25:06Is is this same as multiple times a day,
01:25:09multiple times a day does not.
01:25:12Make anyone win faster and so really,
01:25:15unless there are true good and exceptions.
01:25:18Patients on 10 seven will be
01:25:21placed on SBT only once a day.
01:25:24An unassisted breathing using Trach
01:25:27Mask is our preferred mode of winning,
01:25:30and this should be used as standard.
01:25:34And first choice would all be patients
01:25:38requiring prolonged mechanical ventilation.
01:25:41Who fail? Who passed SPT?
01:25:43If they fail Jake Mask or that SVT,
01:25:46then you can consider the pressure support
01:25:50winning strategy as an alternative.
01:25:53But quite clearly our second choice, yeah.
01:25:56And then you can dress them.
01:25:58Like I said he did on assist control
01:26:00settings or on precious support.
01:26:02If that is more comfortable for the patient,
01:26:04but it's not really a winning strategy.
01:26:10So while on console service anyone
01:26:12any patient who is actively weaning
01:26:15needs pulmonary to be following them.
01:26:17You don't need to follow them every day,
01:26:20of course, but we do expect
01:26:22that you would see them.
01:26:25A couple of times a week at least.
01:26:28There are two huddles with the 10:17,
01:26:31so on Tuesdays at 1:30 via zoom
01:26:33with the 10 Simon leadership team,
01:26:36it includes the primary hospital
01:26:38esteem and Artie Ann is just a
01:26:40discussion of what's happening with
01:26:42the patient as well as a really
01:26:45quick huddle on Thursdays at 1:00
01:26:47PM with the 10 seven Hospice team.
01:26:51Either attending or fellows can attend this.
01:26:54We ask that you please assist with
01:26:57the family meetings with the hospitals
01:26:59because the most of the time the
01:27:02question is are they going to be able
01:27:04to come off the ventilator or not?
01:27:07So our perspective is really helpful.
01:27:10And really,
01:27:11we ask that you sign off only on
01:27:13patients who have been stable on
01:27:16Trach mask for at least 72 hours,
01:27:18and there are no plans of decannulation.
01:27:21Or Alternatively if they have been
01:27:23D candidated and are doing fine
01:27:25then please feel free to sign off.
01:27:31And with that I would just like
01:27:34to acknowledge and thank Ilene,
01:27:36Jonathan Saadani Colon,
01:27:37Michael from respiratory
01:27:39Therapy who helped develop and
01:27:41implement these guidelines,
01:27:42and also the 1017 who who are
01:27:45led by Jenny Sam 2 by Nicole who
01:27:48really taken on this expansion
01:27:51and I've been doing a great job.
01:27:57Thank you, Oscar.
01:28:00Are you doing in the next one?
01:28:03Slowly. It's Adam solely.
01:28:09Doctor dibiase
01:28:12very timely segue into decannulation.
01:28:16That's all we need from chronic.
01:28:19Yeah.
01:28:21So as Oscar outlined our census
01:28:24of chronically Trakt invented
01:28:25patients with the expansion of 10,
01:28:28seven is much higher than it usually is.
01:28:31And as a point of reference,
01:28:33typically the interventional pulmonary
01:28:35service only ends up **** emulating
01:28:38a small proportion of the patients
01:28:40that we perform tracheostomy on,
01:28:42as many or discharge in the path had
01:28:45been discharged outside facilities or
01:28:47Gaylord for continued Ben tweeting and
01:28:50eventual decannulation the literature
01:28:52doesn't really provide us any clean,
01:28:55clear consensus is on the
01:28:57nitty gritty aspects of trach,
01:28:59capping and decannulation,
01:29:01and therefore wide variety exists
01:29:03in practice patterns for this.
01:29:05So recently,
01:29:06the Interventional pulmonary group
01:29:08aasaan representatives from the
01:29:10hospital's 10 seven group meant
01:29:12met to establish guidelines for
01:29:14capping and decannulation in order
01:29:16to help streamline our care and
01:29:18improve our communication and
01:29:21expectations between the groups.
01:29:23Over our goal is to turn the
01:29:25term capping trials which is
01:29:27often referenced in progress.
01:29:30Note into a single capping trial.
01:29:32If we can effectively screen
01:29:35candidates for capping.
01:29:37So in terms of protocol components
01:29:39that the most important aspect
01:29:42of the capping and decannulation
01:29:44protocol is assessing whether
01:29:46patients are ready and so we'll
01:29:48spend a couple of minutes just going
01:29:51over the major aspects of this.
01:29:54More logistical considerations include
01:29:55location of the patient within
01:29:58the hospital so very frequently,
01:30:00once ARP.
01:30:01Oceans are steady off mechanical ventilation.
01:30:03There swiftly moved off of 10,
01:30:06seven to other floors that may not
01:30:08have the capacity to perform capping
01:30:11trials and then more the capping
01:30:13trial specific sanare metrics that we
01:30:16used to assess passing versus failing
01:30:19and different interventions that we
01:30:21can perform if capping does fail.
01:30:24So what we've done is we've put
01:30:27together a guideline to determine
01:30:29whether patients are appropriate for
01:30:32capping and what will plan to do.
01:30:34Is that the console service does
01:30:37receive the guidelines that got us A
01:30:40has put together for mechanical ventilation.
01:30:42Weaning on 10 seven weekly when
01:30:45they start their rotations,
01:30:46we are going to include our
01:30:49guidelines for consideration of
01:30:50capping and decannulation with that,
01:30:52so everyone is aware.
01:30:54But the first thing is,
01:30:56uh,
01:30:57assessing whether the patient has
01:30:59an appropriate mental status and
01:31:01just a quick way to do this is
01:31:03determining whether a patient can
01:31:05affectively remove their cap within
01:31:0730 seconds of it being placed on.
01:31:10If needed,
01:31:10the patients need to be off the
01:31:13ventilator for 48 hours or more,
01:31:15and have stable oxygen requirements
01:31:17below 35%.
01:31:18Their sexually needs also need to be handled,
01:31:21uh, be able to be handled by themselves so.
01:31:25Our guideline is one time no.
01:31:26No more than one time per four hours.
01:31:29The nations need to have an effective cough.
01:31:31We can do this quickly just at the bedside.
01:31:34Asking a patient to cough secretions up
01:31:36to their mouth or through their trach.
01:31:39Active swallowing and we do
01:31:41encourage that this is a.
01:31:43This is evaluated by a formal
01:31:45SLP evaluation and then finally
01:31:47a patient patient upper airway,
01:31:49which would just include just finger
01:31:51occlusion of the trach at the bedside for
01:31:54a minute to assess for stridor or disneya.
01:31:57If the patient meets all of the above
01:32:00metrics, we will document those things in
01:32:02the chart and proceed with the capping
01:32:05trial and so typically what we recommend
01:32:08is that they that rake that's in place.
01:32:10Get capped so we don't necessarily need to
01:32:14downsize or switch to a cuffless trach,
01:32:16although can if necessary and they need to
01:32:20be in a bed that is able to check vitals Q
01:32:244 hours and monitor pulse ox continuously.
01:32:28We ask that abgs be obtained both
01:32:30prior to capping an at the end of
01:32:33the trial and the length of the cap.
01:32:36Trial is what we recommend is 48 hours.
01:32:40So some patients will obviously
01:32:42not pass this.
01:32:43So despite screening some capping failures
01:32:46may occur and so capping failure is is
01:32:50if a cap needs to be re be removed by
01:32:54the patient or the provider for any reason.
01:32:57Indications for the provider to remove
01:33:00the cap, our escalations of their oxygen
01:33:03requirements and or sustained desaturations,
01:33:05subjective shortness of breath or
01:33:07strider or change in the vital signs,
01:33:10including hemodynamic.
01:33:12Instability, takip NIA or fever.
01:33:15So if a patient passes the capping trial,
01:33:18the patient can be **** emulated
01:33:20and we will do so at the bedside.
01:33:23We do recommend that they maintain
01:33:25being able to have their continuous
01:33:27pulse ox checked for 24 hours.
01:33:29After that accumulation occurs.
01:33:31If the capping trial fails,
01:33:33so the cap is not maintained
01:33:35in place for 48 hours,
01:33:37we do have a couple of suggestions
01:33:39for evaluating why the capping
01:33:41trial may have failed.
01:33:43So if it's thought to be
01:33:45potentially an issue with.
01:33:46Upper Airway patency,
01:33:48which we're seeing with increasing,
01:33:50frequently increasing frequency
01:33:51in our post covid patients,
01:33:53we can consider a bronchoscopy
01:33:55to evaluate the upper airway.
01:33:57If it's thought that the trach is
01:33:59potentially too large and there's an
01:34:02element of increased airway resistance,
01:34:04we can downsize that rake or Additionally,
01:34:07if other factors play a role may
01:34:10consider a shorten trial to begin with.
01:34:13So potentially a 12 hour trial
01:34:15followed by the full trial.
01:34:17But what we recommend is that if
01:34:20patients fail that they not just
01:34:22be left alone for another week,
01:34:24and so repeating,
01:34:25screening and doing these assessments
01:34:27if they fail at the time,
01:34:29so that we can continue to move
01:34:32these patients down.
01:34:33This pathway of if appropriate.
01:34:36And so the console service in the
01:34:38Interventional pulmonary Service
01:34:40often are working,
01:34:41sort of in parallel roles on these issues,
01:34:44and so our goal is to help the teams
01:34:46work together with the internal
01:34:48medicine teams in the hospitalist
01:34:50teams to keep patients progressing
01:34:53towards decannulation.
01:34:54In general,
01:34:55the Interventional pulmonary
01:34:56service rounds on Monday mornings
01:34:59and all of our trach patients.
01:35:01As we mentioned before,
01:35:02our senses is much higher
01:35:05than it has been in the past.
01:35:07But our goal on the Mondays
01:35:09is to identify patients
01:35:11that may be candidates for capping or
01:35:13potential candidates down the road.
01:35:15But Additionally, if the pulmonary
01:35:17konsult services following a patient
01:35:19and they identify them as a potential
01:35:22capping candidate later in the week,
01:35:24they can use the checklist to determine
01:35:26candidacy as well an notify us.
01:35:28Recently, since I've been on
01:35:30the Palm Console service,
01:35:31there are patients very few that the
01:35:34IP service has not placed the trach,
01:35:37so most of the.
01:35:38Patients with chronic respiratory failure.
01:35:40the IP services aware of and following,
01:35:44but there are few,
01:35:46either from outside institutions or head.
01:35:49Takes place by surgical services
01:35:51that neither potentially needed
01:35:53pulmonary service or the interventional
01:35:55pulmonary services following.
01:35:57And so we hope to, you know this.
01:36:00This protocol is really geared towards
01:36:03the calculation of medical patients,
01:36:06not surgical patients,
01:36:07but to also help apply this
01:36:10decannulation an capping.
01:36:11Protocol to patients that may
01:36:13not be on our radar,
01:36:16and that's really all I had to tell you.
01:36:19Like I said,
01:36:20the console service will be getting
01:36:23the nitty gritty granular aspects
01:36:25of the protocol in their emails.
01:36:30Great thanks Aaron. One question
01:36:32here from I changed to Cuffless
01:36:34Trach before capping routinely
01:36:36or after first capping failure.
01:36:38We don't do it routinely.
01:36:40We've actually had great success in D
01:36:43calculating patients without cuffless trach,
01:36:45sin and so if the patient has a
01:36:48cuff trach in an we finger occlude
01:36:51and they can breathe around it.
01:36:54We've generally just capped the cuff trach,
01:36:56although if they do fail
01:36:59or have you no evidence of.
01:37:01Increased airway resistance or disneya
01:37:03with it and we will down size to
01:37:05a smaller tracor cuffless trach.
01:37:07OK and there's one more question about
01:37:09use of the trach button in patients
01:37:12who have failed capping thoughts. Uh,
01:37:14we have not routinely used the trade button,
01:37:17and patients that failed capping we have,
01:37:20you know, so these this.
01:37:22This protocol is, you know,
01:37:24a very skeletonized protocol.
01:37:26There's there's room for deviation around it.
01:37:28If patients are, you know,
01:37:30having issues with, for example,
01:37:32secretion clearance or
01:37:33increased airway resistance,
01:37:34but we don't routinely use that. No.
01:37:43Charles had a question about
01:37:44timing of passing your valves.
01:37:47So the PMV can be used really once the
01:37:51patients are off mechanical ventilation
01:37:53and able to a remove the passing your
01:37:57valve if they are in distress and
01:38:00have it on without causing dyspnea,
01:38:03so you know, encouraged once they're
01:38:06off the ventilator to try it,
01:38:08and SLP does a really great job of
01:38:12assessing patients and their their
01:38:14readiness to accelerate the PMV.
01:38:18That's true very good.
01:38:20Thank you very much, Karen.
01:38:23OK, so next John Cough with some
01:38:25updates from cystic fibrosis.
01:38:30Everybody, let me pull up my.
01:38:37Talk.
01:38:41I hope you can see this, thanks everybody.
01:38:44And So what I wanted to do actually
01:38:47is take a little bit of a diversion
01:38:50from from the idea of you know
01:38:53what's new in CF and try a concept
01:38:55of of what can we learn from CF that
01:38:58could apply to other lung diseases.
01:39:00And I queried several of of
01:39:02our colleagues about.
01:39:03You know things that could
01:39:05be interesting here,
01:39:06and I recognize that one of the two
01:39:09most common calls that I receive are,
01:39:11you know what to do about
01:39:14airway clearance in.
01:39:15In non CF well in CF and non CF
01:39:18patients and the other is also
01:39:20specific questions related to inhaled
01:39:23colistin and when to deploy it.
01:39:25We recently have given some some
01:39:27talks about some of the new modulator
01:39:30therapies and I thought Daniel did
01:39:32a phenomenal job of presenting
01:39:34the new therapies for IPF and so
01:39:37in the context of that I think
01:39:40I decided to skip that,
01:39:42but certainly can be something
01:39:44that we can provide later.
01:39:46So in terms of where CF might be able to
01:39:49inform what we do for other lung diseases,
01:39:52I want to highlight for you a couple
01:39:54of things that that we're recognizing
01:39:56about the complexities of the
01:39:58genetics related to cystic fibrosis.
01:40:00So CF is.
01:40:01Uh,
01:40:01there are variants or mutations in
01:40:03the CFTR which ends up producing a
01:40:06chloride channel that's expressed
01:40:08on the surface of cells.
01:40:09There there's an increased frequency of CFT.
01:40:12Are variants or mutations in
01:40:14patients with asthma.
01:40:15See OPD and Bronchiectasis.
01:40:17In addition,
01:40:17larger population studies looking
01:40:19at individuals with obstructive lung
01:40:21disease that has not been characterized.
01:40:23We also see the variance so that
01:40:26becomes an interesting kind of consideration.
01:40:28One of the factors that we're recognizing is.
01:40:32Cigarette smoke actually functionally
01:40:33decreases or suppresses function of CFTR,
01:40:35so it decreases the chloride
01:40:37channel and that results in some
01:40:40of the common path of biology that
01:40:42we see in cystic fibrosis.
01:40:44And while some of that is potentially
01:40:46reversible when individuals stop smoking,
01:40:48the other implication here is that
01:40:51environmental exposures also can
01:40:52mimic some of the effects that
01:40:54we're seeing with cigarette smoke,
01:40:56and that's an error active area
01:40:58of investigation and in with some
01:41:00of our folks in the pulmonary
01:41:02community and specifically in.
01:41:04In our colleagues in CF,
01:41:06who are looking for implications of CSTR
01:41:09modulators outside of cystic fibrosis,
01:41:11and then,
01:41:12intriguingly,
01:41:13the other observation is that TGF beta,
01:41:16when it's increased or the presence
01:41:18of increased amounts of TGF beta,
01:41:21decrease CSTR function and there's
01:41:23an open question and some interesting
01:41:25recent papers about the potential for
01:41:28CF TR dysfunction to be implicated
01:41:31in some of the interstitial
01:41:33phenomenon that we're seeing.
01:41:34And certainly in cystic fibrosis,
01:41:37individuals that have higher
01:41:39TGF beta expression based upon
01:41:41polymorphisms that have been
01:41:43identified have increased severity of
01:41:45disease and in some cases systemic
01:41:48manifestations like liver disease.
01:41:50So in terms of the therapeutics,
01:41:53that might be interesting to this group,
01:41:56I am going to talk about the
01:41:58inhaled antibiotics in a minute,
01:42:00but those are medications that were using
01:42:03or inhaled tobramycin colistin aztreonam.
01:42:05Their emerging studies for
01:42:07inhaled vancomycin for MRSA,
01:42:08say amikacin is is being studied
01:42:10in in the NTM population and
01:42:13also in non NTM patients in the
01:42:16in the CF community and and I'm.
01:42:18I'm highlighting these because the best.
01:42:21Evidence in emerging use of them,
01:42:23but there are there just about every
01:42:26medication that were using Ivy,
01:42:29whether it's carbapenems or
01:42:30fluoroquinolones has been used or is
01:42:33currently being used in some type of
01:42:36inhaled regimen in in CF patients.
01:42:38Obviously an off label Cipro,
01:42:41I think, is the best studied.
01:42:43Most recently as an example and
01:42:46has not gone very far,
01:42:48just given the continued use of it.
01:42:51As an outpatient medication and
01:42:53the concern about developing
01:42:55resistance in addition,
01:42:56everybody's been interested in the use a
01:43:00visa through mice in CF was not the first.
01:43:03Obviously we copied, you know,
01:43:05the the observation from the
01:43:07Japanese data on pan bronchiolitis.
01:43:10We use it for.
01:43:13Secondary prophylaxis for Pseudomonas
01:43:15and in patients for non Pseudomonas
01:43:17without Pseudomonas in their sputum
01:43:19and obviously there's a consideration
01:43:21for its anti-inflammatory properties,
01:43:22but I also highlight for you that
01:43:25depending on how Pseudomonas is cultured,
01:43:27there's evidence that exist for mice
01:43:29and may actually be side all four
01:43:32for Pseudomonas and in the actual
01:43:34kind of environmental characteristics
01:43:35in the in the human.
01:43:38Longer still not clearly defined and
01:43:40so it it may have both functions.
01:43:43And then there's a decent amount of
01:43:46evidence in in CF about decreasing
01:43:48the use of inhaled steroids.
01:43:50If an individual does not have asthma,
01:43:53and I think that has more implications
01:43:56for the individual for overlaps.
01:43:58Kind of diseases with Bronchiectasis for
01:44:00the obvious reasons that if you're colonized,
01:44:03you know the addition of steroids is
01:44:06obviously not helping for control
01:44:08of underlying infections.
01:44:09And then the the other category where.
01:44:13I think CF can provide a lot of
01:44:16information across the pulmonary community,
01:44:18as is with the efforts in quality
01:44:20improvement to highlight the
01:44:22potential for using Qi to develop
01:44:24interventions that can be associated
01:44:26with important clinical outcomes.
01:44:28And obviously I put the multidisciplinary
01:44:30team care model in here because
01:44:33that's a huge effort on the on the
01:44:35CF program side and I think it
01:44:38broadly is broadly applicable,
01:44:39especially as we're moving to North
01:44:42Haven in the in the near future and.
01:44:45You may have access to additional team
01:44:47members and how to deploy them and
01:44:50monitor that and look for potential
01:44:52improvements with that care model I
01:44:55think would be really interesting.
01:44:57Airway clearance therapies is put
01:44:59underneath the Qi section because
01:45:01there are no good trials looking at
01:45:03competitors of airway clearance therapies.
01:45:05But like I said,
01:45:07I'll talk about that in a second and
01:45:09then we huge Qi intervention that
01:45:12I think had enormous implications
01:45:14in CF was the use.
01:45:16Of or the observation that targeting
01:45:18high fat diet to meet new nutritional
01:45:21goal metrics was associated with
01:45:23improved outcomes in patients,
01:45:25and that actually is directly correlate.
01:45:27Stew, improved lung function overtime,
01:45:29and that has us functioning on this
01:45:31model that you I think I've seen us talk
01:45:34about which is the three legged stool
01:45:37here where we have airway clearance
01:45:40therapy on one antibiotics on the other,
01:45:42and nutrition on the 3rd and appropriate
01:45:45interventions and targeting these types of.
01:45:47Therapies allows for stability,
01:45:49disease,
01:45:49stability in this analogy,
01:45:51and obviously if we don't have
01:45:53one of them functioning.
01:45:55So if we're not using a good
01:45:58airway clearance regimen,
01:45:59or if we're not able to deploy
01:46:01antibiotics because of resistance
01:46:03or or using too much antibiotics to
01:46:06engender resistance and then not
01:46:08meeting our nutritional metrics leads
01:46:10to inability to have disease stability.
01:46:13So for the inhaled antibiotics,
01:46:16we have a ton of experience with
01:46:19inhaled to promicin or to be this
01:46:23was the kind of classic paper
01:46:25was published in 1999,
01:46:27really using tobramycin as secondary
01:46:29prophylaxis or maintenance therapy for
01:46:32individuals colonized with Pseudomonas,
01:46:34there was emerging evidence afterwards,
01:46:36especially in the pediatric population,
01:46:39in a in a very elegantly
01:46:42done complicated study that.
01:46:44Unfortunately named the epic trial
01:46:46that was completed in 2009 showing
01:46:49the potential use of tobramycin
01:46:50at first onset of Pseudomonas in
01:46:53sputum culture to try and eradicate,
01:46:56but they the evidence for using tobramycin
01:46:58in as a primary treatment for pulmonary
01:47:01exacerbation and by virtue of that,
01:47:04I think, extrapolating that to to
01:47:07pneumonia and certainly the data that
01:47:09I've reviewed for trying to use it for
01:47:12ventilator associated pneumonia etc.
01:47:14In the.
01:47:15In the ICU is lacking and so I consider this.
01:47:20And that is really used for the
01:47:22eradication or the secondary prophylaxis.
01:47:25Inhaled aztreonam I'm going to skip over,
01:47:28mostly because the data is really bored,
01:47:31bears out for for CF alone because of a
01:47:34study I believe I believe is published
01:47:38in Lancet respiratory medicine showing
01:47:40inability of aztreonam to provide a
01:47:43benefit in a population of non CF
01:47:46Bronchiectasis patients and so the use
01:47:49of aztreonam outside of CF is kind of.
01:47:52Gone by the wayside,
01:47:54but obviously it targets a different
01:47:56microbial pathway and then inhaled colistin.
01:47:59So inhaled colistin has tremendous amount
01:48:02of experience, as you can see here,
01:48:05developed and started use in the 1950s
01:48:08and therefore a lot of the kind of
01:48:12classic FDA type of approval studies
01:48:15that you would imagine would exist
01:48:17do not exist for this medication.
01:48:20It's been used with incredible
01:48:23frequency in Europe.
01:48:24In the CF community,
01:48:26however,
01:48:27the concern that that some of us
01:48:29have is that despite this frequency
01:48:32of use and several studies,
01:48:35there's not a clear signal for
01:48:37benefit in a CF kind of disease
01:48:40organized structure in terms of
01:48:43alternating antibiotics or went
01:48:45to went to use this intervention,
01:48:47and so that does highlight some
01:48:50considerations for this medication
01:48:52from a practical perspective.
01:48:54There are two types of what we're
01:48:57calling colistin polymyxin E.
01:48:58Is this inactive prodrug that is
01:49:01typically available in the United States,
01:49:03while polymyxin B is typically what's
01:49:05used outside of the United States.
01:49:08If I'm if I'm not mistaken,
01:49:10and the considerations here are just
01:49:13to recognize that patients have to
01:49:15prepare this medication at home,
01:49:17and when we have seen complications
01:49:19related to acute toxicity with colistin,
01:49:22there have been issues about.
01:49:24Inadequate preparation of colistin at
01:49:27home where patients mixed it and then
01:49:30let it sit in the fridge for a week,
01:49:33an inhaled it and and developed
01:49:35acute pulmonary toxicity.
01:49:37Probably some form of acute lung injury
01:49:39related to bacterial contamination
01:49:41or or some other type of toxicity,
01:49:44and so there is.
01:49:45There is quite a bit of usually couple
01:49:49case reports a year for that type of
01:49:52complication and a well born out.
01:49:55Literature for it clearly nephrotoxic
01:49:58drug Ivy is much more.
01:50:01Nephrotoxic then inhaled.
01:50:02Although the I would highlight for you
01:50:06that any we are seeing that patients
01:50:08with low lung function are at risk
01:50:11for increased nephro toxicity and the
01:50:14mechanisms mechanisms for that or in CF
01:50:17and post transplant or not clear but but
01:50:20there is some evidence that we are obviously
01:50:24overestimating or creatinine clearance,
01:50:26and some biomarkers are associated are
01:50:29showing evidence for nephro toxicity.
01:50:31In these lung diseases that may put them at
01:50:34increased risk and so that may be relevant
01:50:37for for your monitoring of these patients,
01:50:40there's also evidence that colistin,
01:50:42even though it's a great drug for
01:50:45killing multiple gram negative bacteria,
01:50:47does cause toxicity to the airway.
01:50:49There's a decreased production of
01:50:51antimicrobial peptides and other important
01:50:53proteins from the lung epithelium,
01:50:55and because of that I think it's
01:50:58probably got less of a use as
01:51:01a consistent chronic therapy.
01:51:02And to date we've we've tried this
01:51:04in in a handful of patients to have
01:51:07colistin uses an alternating therapy,
01:51:10but but really have not had success
01:51:12where these patients can tolerate
01:51:14it for an extended period of time,
01:51:17and so that's left us with using
01:51:19colistin as a targeted therapy,
01:51:21typically for 14 day duration.
01:51:23For multi drug resistant gram negatives,
01:51:25and and so I would suggest to you that
01:51:28that's probably the place to deploy.
01:51:30This recently had a case of Pandaria Pista.
01:51:33In ventilator associated pneumonia in
01:51:35the MCU and we you know discuss this
01:51:38with ID and came came out and used
01:51:41colistin as an adjunct to some of the
01:51:43other antibiotics that were being tried
01:51:45for for that multi drug resistant gram.
01:51:48Negative and so that I'm happy
01:51:50to follow up with anybody.
01:51:52If you have questions,
01:51:53but I think that might be a
01:51:56relevant consideration for colistin
01:51:57in our in our non CF patients.
01:52:01And then in terms of airway
01:52:03clearance therapies just in in
01:52:05a couple of minutes here,
01:52:07wanted to say that the patients don't
01:52:09like the phrase pulmonary toilet.
01:52:11They don't think of their lungs as a toilet,
01:52:14so we're trying to get away from that.
01:52:17And so we use airway clearance therapies.
01:52:20I think almost interchangeably
01:52:21with chest physiotherapy,
01:52:22but there are some differences,
01:52:24but the concept really is the same here.
01:52:27We want to use these therapies to try
01:52:29and eliminate excessive secretions.
01:52:31It improved mucociliary function
01:52:33and help cough to function as best
01:52:36as possible and you can see the
01:52:39benefits here range from respiratory
01:52:41mechanics all the way to helping to
01:52:44decrease infection and inflammation.
01:52:45And so I've shown this talk to the
01:52:49start of this slide to the fellows,
01:52:51and we presented in other areas.
01:52:54But to highlight for you the
01:52:56the different devices,
01:52:57the best is the most commonly used
01:52:59therapy for us in our CF patients.
01:53:02Positive expert Tori pressure
01:53:03devices like the acapella anaerobic
01:53:05are available for inpatients.
01:53:07We don't use a lot of cough assist
01:53:09in CF but obviously has an important
01:53:12role in neuromuscular diseases.
01:53:14And then we're increasingly using IPV and.
01:53:17And meta Neb is phenomenal.
01:53:19Potential intervention for us and we're
01:53:22working with respiratory therapy to
01:53:25see if we can include this to into our
01:53:28CF. Armamentarium and Valora is
01:53:30the home version of Meta Neb,
01:53:32and that's essentially AC,
01:53:34PAP and IPV combined intervention
01:53:36that allows for you to also
01:53:39nebulize medications so it can
01:53:40cycle through three different.
01:53:45Settings for use and I've just put down
01:53:47here a slide of pearls that I was thinking
01:53:50about when I was putting this together
01:53:53in one thing that we've been doing is
01:53:55using the vest plus pep devices so so at
01:53:58the same time that you're using the vest,
01:54:01you're also using an acapella aerobica,
01:54:03and that's the ideas of that is to maximize
01:54:06the efficiency of the setting of the session.
01:54:09Best works really well to shake things up,
01:54:12but there's obviously no expert
01:54:13Tori pressure to breathe again,
01:54:15so that's where the pep is synergistic.
01:54:18And everyone has heard us talk
01:54:20about a Minnesota protocol.
01:54:22And this is basically an evidence based
01:54:24protocol that changes the frequency during
01:54:27the best session and it actually does.
01:54:29It's one of the only things where we do
01:54:32have some data for an airway clearance
01:54:35therapies to show that it can increase
01:54:38mucus production or expectoration
01:54:40of mucus and and make essentially
01:54:42makes the session more efficient.
01:54:44So moving to that is is a goal
01:54:47for us for all of our patients.
01:54:50Huff Cough is is a concept that were
01:54:53trying to adopt for all of our patients
01:54:55to keep the glottis open and took
01:54:58off it low float help expect rate.
01:55:00And I found this really interesting
01:55:02that that you know all lung diseases
01:55:04that have been studied or associated
01:55:06with this secondary glottis closure that
01:55:09is not present in healthy controls.
01:55:11So this includes are restrictive
01:55:12and obstructive.
01:55:13Lung disease is the mechanism is
01:55:15unknown but but without the Huff cop
01:55:18you may you may be closing the glottis.
01:55:21Increasing resistance and so some of
01:55:23that mucus clearance could be impaired.
01:55:25So having time for the Huff cough
01:55:27and educating, shooting education,
01:55:28educating patients on Huff cough
01:55:30could be a benefit.
01:55:31I just put in here the typical
01:55:34medication order to dilate the Airways
01:55:36hydrate with sailing TID or BID.
01:55:38Come in with your airway clearance
01:55:40and then use your inhaled antibiotic
01:55:42or or inhalers afterwards.
01:55:43Once you've,
01:55:44you know hypothetically cleaned out
01:55:46the lungs as much as possible and
01:55:48one thing that we've started to
01:55:50do is to monitor air trapping.
01:55:52And there are some limitations with
01:55:54just looking at RV to TLC ratio.
01:55:57In addition,
01:55:57it's not easy to quantify and
01:55:59look at changes,
01:56:01so we've been doing some work on
01:56:03the total lung capacity minus the
01:56:05forced vital capacity targeting
01:56:07a goal of about 500 to 800 M,
01:56:10else an increasing airway clearance
01:56:11of patients are above that goal.
01:56:14In addition to adjusting the inhaler regimen,
01:56:16and I think that's also been successful.
01:56:20So this is one of our patients trying
01:56:22to show you that he can exercise.
01:56:25Do the vest,
01:56:26do acapella and play video games
01:56:28at the same time.
01:56:29Unfortunately,
01:56:29if you for those folks in the CF program,
01:56:32we know the patient,
01:56:33he probably can't do any of
01:56:35those except for the video games.
01:56:37Well, but he's trying which we appreciate.
01:56:39But what I wanted to highlight for you is,
01:56:42you know, in the absence of data the
01:56:45quality improvement aspect to what
01:56:46we're doing becomes really important,
01:56:48and I've always been struck by this
01:56:50observation in the CF community.
01:56:52That looked at comparing the 10
01:56:54best centers to all the rest,
01:56:56and this was done.
01:56:58You know awhile ago now,
01:56:59but in the setting of that they
01:57:02were able to show that if you if
01:57:04you were at one of these achieving
01:57:06centers based upon the data that
01:57:09is reported to the CF Foundation
01:57:11for our Port CF Registry report,
01:57:13there was a mortality benefit and so the
01:57:16idea is at least that I've taken from.
01:57:19It is if we can mimic some
01:57:21of these high quality.
01:57:23Interventions and deploy them.
01:57:25We might be able to help our patients and
01:57:28to tutor or our own horn a little bit.
01:57:31You know we do as well as everybody
01:57:34with having a respiratory therapy
01:57:36clinic and hospital evaluating patients.
01:57:38We do a great job of bringing in
01:57:41a physical therapist to clinic and
01:57:43sorry so where the red line here?
01:57:46The green is the national average
01:57:48and each line here represents one
01:57:51program across the country for the.
01:57:54Program that sees adults so a lot
01:57:56of programs are able to deploy
01:57:59respiratory therapy because that's
01:58:01obviously been apart of the CIA.
01:58:03Program of PT is something unique
01:58:05for us that we've used because of a
01:58:08really generous grant to donation to
01:58:11our program. And then last year pre covid.
01:58:14We obviously had the top program in
01:58:17the country in terms of absolute FEV.
01:58:20One sorry medium.
01:58:21At FV one for adult patients.
01:58:24And I think it also reflects the fact
01:58:26that with this intervention and team
01:58:29effort were were increasing airway clearance,
01:58:32we're seeing evidence across several domains.
01:58:34And then what I'd highlight for you is,
01:58:38we think that we're
01:58:39decreasing lung inflammation.
01:58:40We're definitely decreasing microbial burden
01:58:42when we use airway clearance effectively,
01:58:45we see patients revert from or drug
01:58:48resistant pathogens to to the wild type,
01:58:51right?
01:58:51We see that the resistance patterns decrease.
01:58:54With increasing frequency,
01:58:55which is exciting,
01:58:56we obviously are seeing decreased
01:58:58Palmer exacerbations and one of
01:59:00the reasons that we started this
01:59:02program so aggressively is because we
01:59:04had higher than average hemoptysis
01:59:06episodes of massive hemoptysis,
01:59:07and those have gone down dramatically
01:59:09and so that I think is where I'll
01:59:12stop and just thank everybody who
01:59:15is a part of our program and the
01:59:17leadership that have helped us get
01:59:19get our funding for the program.
01:59:21Thanks everybody.
01:59:25Next, John OK getting towards the
01:59:27end here, so we'll keep moving.
01:59:30Doctor Cilco slow talking about
01:59:31pulmonary embolism, response team.
01:59:33The new decision algorithm
01:59:34rolled out from the summer,
01:59:36and some updates about the process to kill.
01:59:41Q.
01:59:47Alright, so we'll be talking
01:59:49about risk stratification as well
01:59:51as management specifically for
01:59:52intermediate risk PE patients.
01:59:55As a background,
01:59:55we use the European Society cardiology
01:59:57guidelines for stratification.
01:59:59This has been adopted by many.
02:00:01Centers throughout the US.
02:00:03As a reminder,
02:00:04there's three broad categories,
02:00:06low, intermediate and high risk
02:00:07and risk stratification is really
02:00:09based on a few parameters,
02:00:11hemodynamic stability or instability.
02:00:12Presence of RV dysfunction
02:00:14on either CAT scan or ECHO,
02:00:16and then presence or absence
02:00:18of elevated cardiac biomarkers
02:00:20mainly in the form of trip onen.
02:00:23In terms of low risk user patients,
02:00:25very minimally stable without evidence
02:00:27of RV dysfunction and without evidence
02:00:29of increased cardiac biomarkers on
02:00:31the opposite in the spectrum of
02:00:33high risk or massive PE patients,
02:00:35these are patients who present with
02:00:37hemodynamic instability and then
02:00:39in between we have intermediate or
02:00:41submassive and this has been further
02:00:43subcategorized into intermediate
02:00:44high intermediate low risk.
02:00:46Now,
02:00:46the distinction between these two
02:00:48or the intermediate low risk are
02:00:50patients who have either RV dysfunction
02:00:52or elevated cardiac biomarkers.
02:00:54Where is intermediate high has a presence
02:00:56of both elevated cardiac biomarkers
02:00:58and evidence of RV dysfunction.
02:01:00Now appropriate risk stratification,
02:01:02even subcategorization is important
02:01:03because with increased risk is increased
02:01:06in Association with mortality.
02:01:07But it can also help guide treatment
02:01:10and help influence this position.
02:01:13And not only do we use it,
02:01:15you see guidelines to help re stratify.
02:01:17We also want to screen patients
02:01:19for other clinical parameters which
02:01:20may help predict which patients
02:01:22have a higher mortality rate from
02:01:23intermediate risk PE in which
02:01:25patients may decompensate during
02:01:26their admission from there P.
02:01:28So other red flag features that will
02:01:30be screening all patients for an
02:01:32initial evaluation or elevated lactic acid.
02:01:34Syncope or near syncopal events.
02:01:36Degree of respiratory support.
02:01:38Prior cardiovascular and
02:01:39pulmonary disease history.
02:01:41Severity of clot burden and degree
02:01:43of obstruction underlying PFO,
02:01:44especially his right to left shunt.
02:01:48Quad in transit now this is relatively
02:01:50rare 2 to 5% of all PE cases,
02:01:52but does carry a higher mortality
02:01:54rate compared to matched cohorts
02:01:56without clouding transit underlying
02:01:57pregnancy and then one that often goes
02:02:00undetected or sustained abnormal vital signs,
02:02:02especially tachycardia,
02:02:02and in the PE literature in the
02:02:04World Shock Index is commonly used.
02:02:06That's your heart rate divided
02:02:08by systolic blood pressure.
02:02:10With values approaching one
02:02:11or greater being concerning,
02:02:12so not only do we have to evaluate
02:02:14these patients initially,
02:02:15but we need to monitor their vital
02:02:18signs and make sure that they
02:02:20are normalizing during treatment.
02:02:22In addition to these red flag features,
02:02:24there's being more and more literature
02:02:25supporting the use of echocardiogram
02:02:27and further re stratifying patients with PD.
02:02:29Historically,
02:02:30we looked at echo to really tell
02:02:32us if the RV was dilated compared
02:02:34to LV things like McConnell Sign
02:02:36and if there is cloud in transit,
02:02:38but over the last year we've seen
02:02:40other parameters that can be more
02:02:42sensitive and more specific into
02:02:44risk stratification,
02:02:44so the following parameters
02:02:46taxi as priming LVT,
02:02:47I have all been associated to
02:02:49predict which patients will initially
02:02:50present with intermediate risk PE.
02:02:52And then transition to high risk or
02:02:54massive PE and have increasing mortality.
02:02:57So taps in his prime correlate to
02:02:59RV contractility with reduced values
02:03:01indicating poor contractility of the RV.
02:03:04L Vvti is a non invasive surrogate
02:03:06marker for stroke volume and cardiac
02:03:08output and this is probably the most
02:03:10sensitive and specific echocardiographic
02:03:12marker we have at this point to
02:03:15determine which patients are going
02:03:17to decompensate from their initial P.
02:03:21In terms of
02:03:22our approach to
02:03:23patients with PE, we generally have
02:03:25two activations that are available.
02:03:27We have a modified per activation
02:03:29in a full productive nation.
02:03:31The modified code activation is for
02:03:33hemodynamically stable patients,
02:03:34so this is the majority of the intermediate
02:03:37risk PE that you will be seeing.
02:03:40And this is a small scale activation
02:03:42that is sent to both pulmonary and IR
02:03:44to evaluate the patient and you shared
02:03:46decision making for appropriate treatment.
02:03:48Now the full productive aition is
02:03:50reserved for human dynamically
02:03:52unstable or massive PE patients.
02:03:54This is a much much larger scale activation.
02:03:57And really,
02:03:58the goal for this is to obtain multiple
02:04:00resources quickly and efficiently so we
02:04:03can manage these high risk patients.
02:04:05Now there may be a time that you receive the
02:04:07modified part and you evaluate the patient,
02:04:10but they're actually a high
02:04:11risk or massive PE patient.
02:04:12I would ask that this is the case.
02:04:14The police have the primary team
02:04:16called 155 and upgrade to a full card
02:04:18activation or yourself can call 155
02:04:20and upgrade to a full activation,
02:04:21but just allows for those other
02:04:24resource is to be at bedside.
02:04:26Also, all these rules you can
02:04:28access through mobile heartbeat.
02:04:29There's a dynamic role group for both
02:04:32fellows and attendings at both campuses,
02:04:34so if you're on call,
02:04:35please log into that.
02:04:38In terms of
02:04:39our treatment guidelines,
02:04:40we have two pathways for treatment.
02:04:42We have one treatment dedicated for
02:04:43high risk or massive PE patients.
02:04:45There's a medical emergency
02:04:47and a separate discussion.
02:04:48Today we're going to be focusing on
02:04:50the left hand side for intermediate
02:04:52risk PE patients and treatment
02:04:54guidelines really follow other large
02:04:55part centers with the goal of trying
02:04:57to identify and intervene early on.
02:04:59Patients are at high risk for
02:05:02D compensation from their PE.
02:05:04Now the thought is that if we can
02:05:06intervene earlier before they transitioned,
02:05:08a massive PE is probably a benefit.
02:05:10Once patients transition to massive PE,
02:05:12we know the mortality rates
02:05:13increased significantly.
02:05:14Some studies up to 40% despite treatment,
02:05:16and we know that treatment for massive
02:05:18PE with systemic lyrics comes with its
02:05:20own complications and consequences.
02:05:21So we screen all of her patients
02:05:23initially for high risk features if
02:05:25they don't have any of these features,
02:05:27we tend to favor anticoagulation
02:05:29alone and that's what the majority
02:05:31of our patients end up receiving.
02:05:33If there's no high risk features,
02:05:35we tend to favor Lovenox as
02:05:37the anticoagulant of choice.
02:05:38We did monitor them.
02:05:39If there's failure to improve
02:05:40or further deterioration,
02:05:42we then look at advanced therapies.
02:05:45Now,
02:05:45patients who initially present
02:05:47with intermediate risk EBA have
02:05:48some of these red flag symptoms or
02:05:50high risk features that we talked
02:05:52about before such as near syncope
02:05:54sustained abnormal vital signs.
02:05:56Elevated lactate concerning
02:05:57Echocardiographic findings,
02:05:57these are patients that we would
02:05:59offer advanced therapies up front
02:06:01in conjunction with anticoagulation.
02:06:02They try to prevent deterioration
02:06:04during their hospital stay.
02:06:07Now, in terms of advanced therapies,
02:06:08there's a few different types on
02:06:10probably the most common advanced therapies,
02:06:12or Kathy directed thrombolysis,
02:06:14also known as Ekos and Kathy
02:06:16directed and elect me or Float River.
02:06:18We have migrated away from echoes,
02:06:20so for example in the last calendar year,
02:06:22we've only done one to two equals cases.
02:06:25Majority of our cases are all
02:06:27through float River.
02:06:28Well, as a brief overview,
02:06:30the flow tree very easy catheter
02:06:32device that is inserted through
02:06:33the femme access site migrated
02:06:35into the pulmonary vasculature,
02:06:37engage with clot and that cloud
02:06:39is then aspirated.
02:06:40It does not require any TPA,
02:06:42but it does require therapeutic
02:06:44anticoagulation and therapeutic AC T.
02:06:46And no catheters are left in place.
02:06:48As with egos.
02:06:49On the right hand side you can see this
02:06:52is an example of patient we had last year,
02:06:55a 40 year old construction worker
02:06:56who presented with multiple near
02:06:57syncopal events while at work.
02:06:59Now in the Ed was found at Central
02:07:01Clock burden on a CTA with an elevated
02:07:03lactate in high option requirement.
02:07:05He underwent foot reefer device with
02:07:08large amount of clot removed and
02:07:11significant and rapid improvement and
02:07:14his team dynamics and respiratory status.
02:07:17In terms of data,
02:07:18there is some studies showing efficacy
02:07:20and safety of the flow tree device.
02:07:22The most recent trial is still ongoing.
02:07:24It's the flash trial.
02:07:26It's using the float River,
02:07:27can be studied for intermediate
02:07:29risk PE across 19 different sites,
02:07:30where one of the active sites for this trial.
02:07:33The interim results were recently
02:07:35published and it was looking at
02:07:36the cohort of patients in the Flash
02:07:38trial compared to patients in the
02:07:40National Park Consortium database.
02:07:41That's a registry that US part
02:07:44centers upload their data to.
02:07:45And the interim results showed that
02:07:47patients who underwent full tree
02:07:48for intermediate high risk PE had
02:07:50findings of reduced readmission rates,
02:07:52reduced mortality and improvement
02:07:53in hemodynamic variables.
02:07:53So it's going to be really interesting
02:07:56and exciting to see what the
02:07:58final data shows from this trial.
02:08:00Little bit of background from our program,
02:08:03so we average roughly 20 alerts
02:08:04per month between both campuses.
02:08:06Of those 20 alerts,
02:08:07roughly four of them per month or
02:08:10of high risk or massive PE cases.
02:08:13In the last quarter for 2020,
02:08:15so the three months we had 31
02:08:17intermediate and high risk cases.
02:08:1914 high risk or massive PE cases,
02:08:21we deployed the Float River 15
02:08:23times in that quarter and had zero
02:08:25procedure related complications.
02:08:26In fact,
02:08:27throughout calendar year 2020 we
02:08:29had no device related complications
02:08:30from float revert stuff.
02:08:35In summary, appropriate
02:08:35risk stratification and the appropriate
02:08:37per activation is very important.
02:08:38Please screen all patients for any red flags.
02:08:41Symptoms to determine if there
02:08:42are risk for D compensation.
02:08:44We tend to favor advanced therapies for
02:08:46patients are at risk for D compensation
02:08:48and our part continues to provide a
02:08:50vital service for patients with VTE.
02:08:52If there ever any clinical questions or
02:08:54concerns for patients with PE or the current,
02:08:56feel free to call or contact me via email.
02:09:00Thanks.
02:09:01Thanks Akhil, very interesting indeed.
02:09:03Had a question about.
02:09:05I guess when called and what may
02:09:07seem to be an acute situation.
02:09:09How you distinguish between chronic,
02:09:11chronic, and acute peas?
02:09:15Yeah, so it's often something that comes up.
02:09:17We do want to try to avoid using the
02:09:20Float River device and chronic PE.
02:09:22Ideally if an echo was done,
02:09:23we can look at the right ventricular
02:09:26systolic pressure and look at the RV
02:09:28wall to see if it's hypertrophied.
02:09:29If the right ventricle systolic
02:09:31pressure is significantly elevated,
02:09:32that can be assigned a
02:09:34sign of chronicity as well.
02:09:35If there's evidence of RVH on the echo,
02:09:37that can be a sign of chronicity.
02:09:40In addition, there's some see
02:09:41T findings that might indicate
02:09:43classical CTF rather than acute P.
02:09:46So you probably would expect
02:09:48less biomarker elevation.
02:09:49Things that go along with if it's
02:09:51somebody short of breath and and somebody
02:09:53evaluates them and finds, say, RV strain.
02:09:56But there's no biomarkers that would
02:09:58put them into a low risk and you.
02:10:01Have time to sort some of those things out.
02:10:03Just trying to get off India has more
02:10:05to put in on that question left.
02:10:08OK. Alright, thank you.
02:10:12Alright, so we will finish up with
02:10:15something very timely for the spring
02:10:17is we're in our second wave post.
02:10:19Covid Karen Clinic for Denise Ledgemont sing.
02:10:55Hi everyone.
02:10:59I'm just gonna jump into it pretty quickly,
02:11:02so just a little bit about our program.
02:11:05The recovery program was
02:11:06created in June 2020,
02:11:08but we began seeing our first set of
02:11:11patients in April after the first wave.
02:11:14This is one of our patients who is
02:11:17featured in the Washington Post,
02:11:18and unlike the majority of our patients,
02:11:21Edison required ICU care.
02:11:23In fact, more than 50% of the patients
02:11:25being seen in the post Covid Clinic
02:11:28never required hospitalization.
02:11:30And by WHO criteria were defined
02:11:33as having mild disease?
02:11:35In terms of referrals to date,
02:11:38we've had 250 referrals.
02:11:40The core component of our program is
02:11:43collaboration with physical therapy,
02:11:46and we have fostered collaboration with
02:11:49other multidisciplinary specialties,
02:11:50particularly cardiology and neurology.
02:11:52As we've recognized this to
02:11:54be multi systemic problem.
02:11:59In terms of available data,
02:12:01just like everyone else,
02:12:03we are learning about post covid
02:12:05symptoms and post covid symptoms.
02:12:07There is limited data in the US population,
02:12:11but studies have been provided from
02:12:13countries like Italy and China who
02:12:15affected early on in the pandemic.
02:12:18This is an Italian study that looked
02:12:21at 179 patients who are hospitalized
02:12:24and this is the acute follow up care.
02:12:27Patients were affected at least
02:12:2930 days post hospitalization and
02:12:31reported significant dyspnea and
02:12:33fatigue as their most common symptoms.
02:12:35But there has been a wide range of
02:12:38symptoms reported among patients.
02:12:43One of the things that we found
02:12:45very interesting and has been widely
02:12:47reported and commented on is the very
02:12:50protracted course that patients have
02:12:52been experiencing in their recovery
02:12:54phase and this recent study in The Lancet
02:12:56demonstrated that quite well this looked
02:12:59at 6 month consequences of COVID-19 in
02:13:01patients discharged from the hospital
02:13:03and is a fairly large cohort study.
02:13:05The patients were grouped into three
02:13:08categories according to severity of illness.
02:13:10Categories will, basically they
02:13:11required no supplemental oxygen.
02:13:13It required some supplemental oxygen,
02:13:15and then they required Ida high flow,
02:13:18noninvasive ventilation and
02:13:20mechanical ventilation.
02:13:21Even in those patients who did
02:13:23not require supplemental oxygen,
02:13:25there was reduction in six minute
02:13:26walk test and the Fusion impairments
02:13:29were more commonly reported in those
02:13:31who required either ventilla Tori
02:13:33support or supplemental oxygenation.
02:13:35At least 50% of hospitalized patients have
02:13:38at least some Siti abnormality at discharge,
02:13:41and that usually involves
02:13:43groundglass abnormalities,
02:13:44and it's similar to findings reported
02:13:47with influenza and SARS one.
02:13:51The learning point that we've really
02:13:53taken home from the clinic, however,
02:13:56is that the symptom burden is not reserved
02:13:59for those who had severe disease.
02:14:01This was a Canadian study that looked
02:14:04at 150 patients who were not considered
02:14:07severe disease by WHL criteria,
02:14:09but we evaluated 30 days after
02:14:12and 60 days after,
02:14:13and most patients reported persistent
02:14:15symptoms at 30 days and 60 days.
02:14:18Quite commonly,
02:14:19disneya was reported in at least 30 patients.
02:14:23One of the things that's very
02:14:25important is that it's not necessarily
02:14:27older patients who are experiencing
02:14:29persistent symptoms of patients between
02:14:31the ages of 40 to 60 years of age.
02:14:34We're very much affected,
02:14:36and since a lot of our patients,
02:14:38we essential workers and healthcare
02:14:40workers that has long term
02:14:41implications for the workforce.
02:14:45So the pulmonary clinic on the recovery
02:14:48program has been seeing a number
02:14:50of patients for over six months,
02:14:53and we've realized that post covid
02:14:56respiratory symptoms are not a single entity.
02:14:59We've seen a range of manifestations
02:15:01and phenotypes an although the
02:15:03thing that everyone worried about
02:15:06the most was whether patients would
02:15:08develop interstitial lung disease,
02:15:10that those patients actually a very small
02:15:13proportion of our patient population.
02:15:16The phenotype that has been
02:15:17emerging on is one that is reported
02:15:20in the literature literature.
02:15:22An true observations is the patients
02:15:25with persistent symptoms out of
02:15:27proportion to investigations.
02:15:28Normal PFTS and normal imaging.
02:15:33So the phenotype that we find the most
02:15:36challenging in terms of evaluation is this
02:15:39phenotype of normal testing with persistent
02:15:41symptoms through internal evaluations.
02:15:44On recent collaboration we've revamped
02:15:46or testing algorithm after we've sent a
02:15:50couple patients to do level one cardio,
02:15:52pulmonary exercise testing.
02:15:54Brian Clark helped us out very early
02:15:57on and we realized that most of these
02:16:00patients on testing had no cardiac or
02:16:03ventilatory limitation, but there was.
02:16:07Hyperventilation noted there's a lot of.
02:16:11Theories that exist as to why these patients
02:16:14have dyspnea and hyperventilation made us
02:16:16wonder about the possibility of autonomic
02:16:18dysfunction as a contributing factor.
02:16:20There's also several thoughts that
02:16:22maybe the patients experiencing
02:16:24more fatigue and dyspnea,
02:16:25and that's why they're
02:16:27reporting shortness of breath.
02:16:28And there's also concerns about myopathy,
02:16:30but we've not found any
02:16:32objective data of this,
02:16:33so the plans for the patients
02:16:36going forward is if they fail to
02:16:38respond in a timely manner within
02:16:40a three to six month period.
02:16:43We will be working with Phillip
02:16:44and indeed to put some of these
02:16:47patients through a level 3C Pap.
02:16:51So. Management has been very.
02:16:54Challenging and it still
02:16:56largely on a case by case basis.
02:17:00We do think it's important to
02:17:02acknowledge that there is great
02:17:04heterogeneity in the patients
02:17:06that have pulmonary symptoms,
02:17:08and often there's frequent
02:17:09extrapulmonary contributors because
02:17:11of the concern for dysautonomia and
02:17:13some reports of pot like syndrome.
02:17:16Collaboration with cardiology
02:17:17has been very valuable.
02:17:18Some patients have required oral
02:17:21corticosteroids for postinfectious OPI,
02:17:22but that's not the majority.
02:17:24Most patients even do.
02:17:26They have significant radiological.
02:17:28Findings have had radiological
02:17:29and PFD improvement with just
02:17:31supportive care and not intervention.
02:17:33Bronchodilators are still effective
02:17:35for those with the airway phenotype,
02:17:37evidence of air trapping on PFTS octi.
02:17:40So we have been utilizing that
02:17:43more liberally in those patients
02:17:45and we are hoping that the level
02:17:483C Pad will help us to clarify the
02:17:51pathology and help us determine
02:17:53additional interventions.
02:17:53Also,
02:17:54physical therapy has really been
02:17:56the most effective intervention
02:17:58that we've had for these patients,
02:18:00but there's still opportunity.
02:18:02But determine what is the specific
02:18:04post covid approach in rehab
02:18:06that is still unclear.
02:18:08So in terms of recommendations
02:18:10for people who may have patients
02:18:12who they are seeing on their own,
02:18:14we do point out that there's significant
02:18:16subjective objective mismatch.
02:18:17It doesn't indicate that there's
02:18:19lack of pathologies,
02:18:20just that we have not understood
02:18:22yet what is driving the display
02:18:24in some of these patients,
02:18:26it's very important that patients
02:18:28feel heard and and they understand
02:18:30that we are trying to support
02:18:32them through these strategies and
02:18:33is also very important that we
02:18:35don't over test them as often.
02:18:37It leads to very little valuable information.
02:18:41If people have patience of
02:18:42their own who've had covid,
02:18:44and they have new respiratory symptoms in
02:18:47terms of an approach that may be helpful,
02:18:50repeat PFTS in six minute walk.
02:18:52Test may be of some utility screening
02:18:54for venous thromboembolic disease
02:18:56or cardiac pathology has also
02:18:57been helpful from our standpoint,
02:19:00and it's also important to reinforce
02:19:02these patients that the timeline
02:19:03for recovery is alone.
02:19:05Patients are still with us six to
02:19:07nine months after their initial
02:19:09insult with persistent.
02:19:11Sometimes rehab is very helpful
02:19:13for those patients who do not
02:19:15qualify for pulmonary rehab.
02:19:17We have referred them to general rehab,
02:19:20strengthening and conditioning and
02:19:22these patients have found that
02:19:24helpful because a large proportion
02:19:26of patients affected have either.
02:19:28Healthcare workers are essential workers.
02:19:30The return to work question comes up
02:19:33repetitively during the interactions
02:19:35and we suggest a low threshold for
02:19:37referral to occupational medicine
02:19:39and we're always happy to.
02:19:42Review or discuss any cases with anyone.
02:19:45Thank you.
02:19:49Alright, thank you.
02:19:50Denise is a good way to
02:19:52end up see any questions.
02:19:54I think it's after five.
02:19:56So everybody's they held out for this
02:19:58finality, but it's time to go so anyway.
02:20:01Everyone on the a lot of the the diagrams
02:20:04and things we can send out to people.
02:20:07Some of the work flows in the process
02:20:10is so please reach out to me if
02:20:13you want any particular slides or
02:20:16information about what was presented,
02:20:17particularly for post covid
02:20:19and workflows around then we
02:20:21need Andy cannulation capping.
02:20:22So thanks everyone.
02:20:23Have a good evening.
02:20:27Thank you Jonathan for
02:20:28organizing this. I think we had an amazing
02:20:30retention. We started with 100, went out,
02:20:33went up 207 and then went down to 72.
02:20:35So that's really good or it went up.
02:20:39Then my suggestion is next time we do it as
02:20:42a CME event, probably a morning,
02:20:44I think the success of
02:20:45this suggests that this there
02:20:47will be a lot of interest,
02:20:48so this was
02:20:49great, thank you.
02:20:52Thank you, have a good night.