re: Interesting article on COVID

This looks like it was written by a non physician. As an ER physician I will give you my take.

1. Some of what is in this article is correct. We do now know that the virus attacks hemoglobin which may contribute to the extremely low oxygen saturation we are seeing. However this has just been described in one paper and we are not sure exactly what the actual clinical effect of Covid on hemoglobin is yet. We are also not sure how to treat this. Carbon monoxide poisoning is a good comparison in a way however the pathology is very different. Ochsner is doing a trial of hyperbarics which theoretically should help but I don’t think it corrects the hemoglobin issue. Methemoglobinemia is a better comparison, but still a different pathology so I don’t think treatments for methemoglobinemia would help either. The author suggests red blood cell transfusion. Not a bad idea, but the red blood cells that the patient gets would provide temporary relief, if any, as those red blood cells would then be attacked by the virus as well.

2. I will disagree about his theories on free radicals from iron causing most of the lung damage. While some of this may be true, we know the virus directly attacks the lungs, in addition to whatever effect these iron ions might be having. He says that this is not ARDS. He says that intubation is not helpful. Both of these are wrong. We are finding that this is an atypical form of ARDS. The patients do not have difficulty getting air into their lungs like in traditional ARDS, however patients have generally responded to typical ARDS protocols when intubated. The notion that intubation is not helpful is actually kind of retarded, because the alternative is to just watch your patient die.

3. There are still no good studies showing benefit of hydroxychloroquine or azithromycin, whether alone or in combination. There are currently some good, ongoing, randomized placebo-controlled studies and hopefully those studies will be positive and come out soon, however based on the current data many docs are not prescribing it. Anecdotally, Ochsner in New Orleans has not seen any improvement of their patients on these meds.

4. The author has obvious biases that should make anyone wary of what he is saying and should prompt one to verify his claims.

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The author has obvious biases that should make anyone wary of what he is saying and should prompt one to verify his claims.

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The quickest way to verify what he discusses is to refer to his sources that he is citing. Complete list included at the end of my post.

I have heard and read observational accounts that lung compliance is typically high and that typically it is not requiring high pressures to ventilate these folks. Some are suggesting that this behaves more like HAPE with paticular regard to apparent hypoxic vasoconstriction (Gattinoni, et. al.), which logic would suggest, could fit with a model whereby there is some deleterious effect on the O2-hgb dissociation curve.

With regards to something that was alluded to above cwil177, what modality of NIPV are you guys using at your institution, and do you believe the white paper from the Vaoptherm people that virus shedding is lower with their HVNI with surgical mask is less than patient with tidal breathing and no mask and less than NC at 6LPM w/ a mask?

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have heard and read observational accounts that lung compliance is typically high and that typically it is not requiring high pressures to ventilate these folks

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I've seen it both ways

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what modality of NIPV are you guys using at your institution,

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Bipap in negative pressure rooms, mostly

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do you believe the white paper from the Vaoptherm people that virus shedding is lower with their HVNI with surgical mask is less than patient with tidal breathing and no mask and less than NC at 6LPM w/ a mask?

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I don't think I'd believe that. But I'd use it in a negative pressure room as well