FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with ACCME guidelines.

MODERATOR: Thank you very much. Welcome to the [INAUDIBLE] Clinic [INAUDIBLE] Critical Care Conference. Today we have a fantastic panel on update on COVID- 19 in the middle of the crisis. So I would just like to introduce all the speakers.

We have experts really from around the world who have been in trenches and have the best trusted evidence that we could use of how to respond to this. For those of us who are just starting and for those of us who are in the middle of it and maybe for those of us who are already getting over it. So if you can just quickly introduce yourself and just what are you doing. So Yaseen.

YASEEN ARABI: Yaseen Arabi. I'm intensive pulmonologist. The chairman of ICU at King Abdulaziz Medical City Rehab. I've been involved in MERS-CoV for years and now in the COVID-19 reearch, and currently finalizing the trial for MERS-CoV.

MODERATOR: Chris? Mute. You're muted.

CHRISTOPHER FARMER: Sorry. Chris Farmer. I am a critical care physician, emeritus professor for Mayo Clinic, prior background in the military, and worked with Homeland Security here in the United States as a liaison for the Surgeon general. And while at Mayo Clinic, was also the Director in Rochester for Disaster Preparedness. And I'm a Past President of the Society of Critical Care Medicine.

MODERATOR: Thank you. Dr. Wang? You can unmute yourself, Dr. Wang. If you can just say something about yourself. OK. David.

DAVID KAUFMAN: Hi, my name is David Kaufman. I worked at the NYU School of Medicine in New York City. And in the past two weeks I've taken care of around 40 patients with COVID-19.

MODERATOR: Thank you. Damien. I can't hear you Damien.

DAMIEN: You can't hear me?

MODERATOR: Now, I can. Yeah, go ahead.

DAMIEN: Yes. I work in the Northeast of France, which is very affected since three weeks by COVID-19. And to date we are to care for 130 patients critically ill.

MODERATOR: Dr. Wang?

DAMIEN: I'm an anesthesiologist specializing in ICU.

MODERATOR: Thank you. Dr. WANG? Just introduce yourself.

MALE SPEAKER: Dr. Wang, please introduce yourself. Yes.

DR. WANG: Nice to meet you. Can you hear me?

MALE SPEAKER: Yes, we can hear you.

DR. WANG: I'm Dr. Wang and I come from Guandong Provincial People's Hospital. And I work in intensive care units. Last month, I work in a hospital to many patients of COVID-19. The mission is that to stop the patient from-- The first thing is that should stop the patient from a severity condition to critical one.

And secondly that to maintain the patients-- let them, especially for mechanical ventilation, and then to find out some opportunity to wean them from the ventilator. And some of them finish some procedure, a special procedure. So actually is useful for today's discussion.

MODERATOR: Thank you. Maurizio?

MAURIZIO CECCONI: Hello, everyone. I am Maurizio Cecconi. I'm a professor of anesthesia and intensive care at Humanitas Research Hospital and Humanitas University in Milan. Before coming back to Italy, I was working for 14 years in the NHS in London and I'm also the President-elect of the European Society of Intensive Care Medicine.

MODERATOR: [INAUDIBLE]

MALE SPEAKER: Hello, everyone. My name is [INAUDIBLE]. I'm from Beijing [INAUDIBLE] Hospital and China Academy of Chinese Medical Science. And I'm one of the China's national experts against-- well, the China national team against the COVID-19. So my focus is on the integrated medicine approach for COVID-19.

MODERATOR: [INAUDIBLE]. Peng Jiang? Can't hear you. OK. I think while we're trying to have reach, let's start with the first lesson. So I have like five contentious questions that have come up through this. So first question, and I will start with Dr. Farmer. So how someone prevents collapse of the hospital and the health system in a city.

CHRISTOPHER FARMER: Well, there's a lot of issues that come into play. And once the disaster starts, you're basically having to do all of your things in real time. So not having a disaster preparedness plan is a big problem. And most of the hospitals, and I'm speaking for the United States, have not done a good job prior to a disaster with operating because largely they're in competition with each other.

And that goes with sharing medical supplies and medical devices and so forth. One of the things that's a hallmark of these sorts of events is they're not bad everywhere at the same time. So it's important that the equipment is shared. And so one hospital in one part of town could make it in another part of town to provide them equipment.

Or another thing that they can do is sharing some of the personnel. And I've seen in past disasters reticence to do that for fear that the personnel will not come back to their original hospital. So it really requires a lot of cooperation. The good news is when a disaster occurs a lot of those barriers fall, but there's still a lag time for people to come forward and assist because of plans not previously in place.

MODERATOR: Thank you, Chris. Maurizio, what works? We know all the things that don't work. We've seen them. What works?

MAURIZIO CECCONI: Well, I will go back to what Chris was saying. For us, we actually, we woke up on the 21st of February with a disaster. Because I would like to remind everyone the specificity of the Lombardy situation is that up to the 20th of February, we didn't have cases that we were not able to trace back to an index patient. So someone that had traveled to China or was a positive case before.

So after that moment we were able to basically trace back everyone and to isolate contacts or [INAUDIBLE] contacts with [INAUDIBLE]. On the 21st of February, we realize that from the day before we already had one patient in one of the intensive care units in the area, young, and with no history back to any contact case. For us, we basically realized suddenly we had a secondary cluster to deal with.

And the only way that we were able to manage these was actually the fact that the government very quickly called an emergency network of ICUs that was already available before this. And that's because we have a network of ICUs that collaborate for ARBs and for cardiac failures when we are already organizing a network.

And I will say that's probably what saved us from collapsing in the first days. Because we made a decision with the network, which is a network instituted a few years ago by Antonio [INAUDIBLE] from Policlinico Alberto Zangrillo from San Rafaele. And then from that network we basically started the COVID-19 [INAUDIBLE] ICU network extended to every hospital. But with that very early group of intensive care. We were able to create immediately isolated cohort of COVID-19 units.

And we were given the time to warn the other hospitals to do the same. So because for me the two principles that have worked and that can only work, and you should never compromise with these two principles wherever you are with these three of this pandemic, is that you need to increase your research capacity for ICU and for other acute patients, but at the same time, you need to guarantee containment.

What you don't want is that you have containment in the community but you don't have containment in the hospital. So you need to separate floors as much as possible. Otherwise they run the risk, you would do run the risk that your all hospital becomes a cluster. That could be a disaster. So working in networks that can give you that extra flexibility of beds that you don't have maybe. But you can allocate this patient when you create your own units there.

So I would say that definitely works. I can see that containment if it's done very early does work. In the region, in Lombardy, they did some very fast containment on one area in the south of Lombardy didn't work very well. Probably we didn't do as fast containment in one city, which is called Beramo. And the clinicians and the scientists we were actually asking to have a stronger containment there.

Maybe even a couple of days would have made a difference on the number of infected cases there. So I would definitely say this battle you don't win just by increasing capacity in hospitals. You really need to work with public health authorities and government. And you actually you need to be very happy when they decide to put some maneuvers in place if they see that the R naught of the virus is out of control. When we discovered the cluster I think our R naught would have being higher than two or three, which is very, very high.

It means that with 10 people they can pass it to thousands of people. Now, we looking at the numbers, we are seeing the disease finally approaching 1 and we want to bring it below 1. But these two principles have to be in place immediately. Increase your capacity and contain the virus in your hospital and in your community.

MODERATOR: Thank you so much. I think that was very detailed and right to the point from disaster preparedness, getting the network, sharing resources, isolating not only the community but isolating floors in the hospitals to prevent clusters and basically the infection spreading throughout the hospital, where the hospital becomes the [INAUDIBLE] of infection. And that's a disaster immediately getting to happen. Any other thoughts that we-- because I want to move forward.

OK, now let's say our politicians, public health, they let us down. We are in front of the situation that we have. So at the level of the hospital and intensive care, obviously the resources, the ventilators, and intubation, and this is here. Yes, so it's a week plus of intensive care. So what had worked to prevent intubation?

So I want to start first, triaging systems. So not everyone benefits from intubation and intensive care. In America, we have so-called advanced directives and people may say, I don't want to ever have it and other things. So ethical, practical challenges in emergency triage of intubated patients. Maybe, David, you want to say something and we can kind of go from then?

DAVID KAUFMAN: Trying to figure out-- OK. Just trying to figure out, make sure I'm not muted. Fortunately, in New York City, at least at NYU, we have not confronted the dilemma of having to decide whether or not to intubate an individual patient because we have so far had enough mechanical ventilators and enough ICU capacity to accommodate all of the patients.

But as with everybody else, we know that those are not infinite resources. And since we appear in New York City to be still in the rising part of this tide, we anticipate that within a couple of weeks at most we will be in a position where we have to triage and ration ventilators.

The ethical decisions are especially complicated in New York City because we have a large population of certain ethnic groups and cultural groups most specifically folks who belong and subscribe to the Orthodox Jewish faith and traditions who have very strong beliefs about the religious considerations and limiting end of life care.

But even in those situations with careful negotiation and good compassionate conversation and bedside care, we've been able to limit some end of life interventions in folks who are either very old and frail or have a lot of comorbid conditions. It takes a lot of time. It takes a lot of sensitivity. It takes a lot of compassion. But the work is worth doing.

MODERATOR: Other approaches to triaging or avoiding patients in patients who may not benefit from it including other interventions such as CPR, [INAUDIBLE], et cetera. Maurizio?

MAURIZIO CECCONI: You know, we've been very highly affected by a huge volume of patients here. But despite there are a lot of documents going around about triage hours and rationing of care and this and that, I really think those documents should be used in very extreme situations, maybe even more extreme but what we are experiencing here, which was one of the worst epicenters in the world.

That's why to me the principle of increasing capacity is particularly important for me. This is not any different than any other ICU patient before. What I'm doing and trying to do exactly the same before. Whether I had 1000 free ICU beds or not. Of course, it becomes very important that you maintain this approach.

And it's not so easy when you have eight patients coming at the same time that may require an intubation in the next hour. So you need to be very fast in this assessment. And these are pros that you have. But before going to rationing, I think is very important to try to do simple things and to do that assessment and goals of care as early as possible for that patient, for that individual patient, not for the others. And I think if you do that, it's amazing how much resilience you can build into the system.

MODERATOR: Fantastic. I really like this. Dr. Farmer?

CHRISTOPHER FARMER: Yeah, Maurizio is right on target with this. I would like to additionally add to that it's extremely important that people are consistent. And in many of these situations, they have a ventilator czar position or role who oversees from a macro level, the utilization of the ventilators. Some of that has to do with triage but it has to do with consistency of application.

Last week Jean-Daniel Chiche shared a document that just used the state, the basic ARDS net criteria and using PF scores, keeping it simple, understanding that not everybody has the same level of sophistication but will be called upon to manage these patients. And a to-do list at each decrementing level of PF ratio of what you should be doing with the ventilator to ensure some consistency.

And that you don't potentiate the injury with that. And I think that's particularly important because one of the things that's confused me from a distance with this is the exceedingly high mortality for ARDS. Why is this different than other forms of ARDS that we've managed for the last 50 years, and yet the mortality is so high?

And I don't understand that. But I do think it makes it extremely important that we carefully manage pressures and flows and other things that we would normally do for these severe ARDS patients. And in that regard again, maximal consistency among all the folks that are turning the knobs on the ventilator.

MODERATOR: So before we get on a ventilator, I just want to ask, and maybe we start from our Chinese colleagues. Are any ways OK-- the patient wants to be intubated and so it's according to the goals of care. But in my-- I've been doing ARDS for 10 years-- not everyone needs to be intubated. In all studies across the board, approximately 1/3 of the patients don't have to be intubated.

And tricks to doing it are multiple. One which we don't have now as easily is basically sitting at the bedside and providing psychological support during that kind of critical moments until you can get over there to prevent the spiral with anxiety.

And this makes it very difficult. I think the constraints of protective equipment are very [INAUDIBLE]. What are the things I know that the [INAUDIBLE] told, like, for example, they're using a Capella valve and things like that for the little [INAUDIBLE] during the coughing fever phase and some Chinese traditional medicine.

And then when I hear from Europeans later and others. Any tricks to prevent intubation or you just really have to intubate nine out of 10, which has been so far published? So Dr. Wang, what can we do to prevent intubation? What worked for you?

MS. WANG: I think we have to do a lot of procedures in details. The first thing that is that we have to maintain the function of the cough and the deep breathe and then to make the there's small airway function is a normal condition. So we have to do some special procedure. Although it may be dangerous in some patients, it be well protected.

And then I think to do some [INAUDIBLE] treatment to the patients and to make it all movements of the lung and then to make the small airway can be in a very good condition. And then you can get the sputum outside. And then prevent from the small airway full of the sputum and then to make the lung function in a good condition.

And then we can find out the mechanical ventilator. In the patient diagnose is the obvious. And then we find out the title [INAUDIBLE] is sometimes very high and sometimes very low. That means the sputum means more airway maybe movement.

So it is in that condition, we can't use that much higher [INAUDIBLE] than normal. And then we can download the [INAUDIBLE] and then match the sputum, can be cleared. [INAUDIBLE].

MODERATOR: For intubation-- uh huh, go ahead.

MS. WANG: And then another thing is that when the patient's due to receipt of the [INAUDIBLE] now you receive when duration and then we can find out a lot of gas in the gastrointestinal. And then maybe if we don't pay attention to the gas in the gastrointestinal and then the maybe it can cause the pressure of the abdominal is very high.

And then in that situation the divisions may maybe intubated in a wrong way. Because a lot of gas in the intestinal. And they're made to feel uncomfortable abdominal function is normal. So we can think about a lot of things to move the gas from the intestinal and then in Chinese, in China, we could use the old traditional Chinese medicine, sometimes the movement of the gastrointestine function. And then we can stop to patient, prevent from the patient intubated.

MODERATOR: [INAUDIBLE] Xuanze, you say you have been using and everywhere in China. I have to say it, it's no-- there are no good studies but people have universally using [INAUDIBLE] as an anti-inflammatory medication in the early stages of disease. And you are a firm believer of this. I just cannot not give you a podium to say something about the approaches before the intubation that could potentially work.

XUANZE: Yeah. Because we have successfully managed it, I think not only from China, but a lot of patients from London from New York. So we use the same formula to reduce the fever initially. Because as you know, the first week and the second week is totally different.

The first is the fever window, and then the 20% may become saturation after the [INAUDIBLE]. So the major focus should be on [INAUDIBLE]. So to reduce the inflammation, I reduce the [INAUDIBLE]. And then the [INAUDIBLE] is very good to help us to restore homeostasis.

Because initially, we know that's a [INAUDIBLE] injury but after about a week that will give you that. So the [INAUDIBLE]. So the [INAUDIBLE] helps. And another thing, during the second week of the initial window, the thing we could do to avoid intubation to [INAUDIBLE]. That's the first thing. And the second one is the [INAUDIBLE] transdermal therapy. [INAUDIBLE] some kind of thing to do the transdermal therapy. That will work very effectively on stopping your cough.

MODERATOR: This transdermal therapy has found ways of controlling your cough without [INAUDIBLE].

XUANZE: Yeah, very important because otherwise the cough--

MODERATOR: [INAUDIBLE] just quickly before we move forward to high [INAUDIBLE] and standard [INAUDIBLE]. Any side effects from [INAUDIBLE] to anyone?

XUANZE: No. I don't think that-- there is nothing. Because even you are mild, it doesn't matter.

MODERATOR: [INAUDIBLE].

XUANZE: It will not increase your adverse affect. So I think that's very sick. And then regarding transdermal therapy, it's also very sick.

MAE SPEAKER: Sounds good. [INAUDIBLE]. Sorry to [INAUDIBLE] Maurizio wanted to say something. Yes, go ahead.

MAURICIO CECONNI: I'm not going to make specific comments about the [INAUDIBLE] because I didn't know and I didn't know the data. I would just like to say remember that we are against a disease that is very serious but that does not have 100% fatality rate.

That means that with all these adjunct therapies, whether it's one drug or the other, I would be very careful before evidence comes out to make strong statements about using this and that. And the strongest evidence that we have is supportive care at the moment. Otherwise, I think we have to find a compromise between doing a drug that we think that may have a benefit but hopefully also recording some data in the most [INAUDIBLE] way as possible because--

MALE SPEAKER: We are [INAUDIBLE].

MAURICIO CECONNI: Can I finish? And just saying because we have to be careful with everything that we do and does not harm the patient. And this is for any drugs that we have. I do hope that we will find something. But I think what we should recommend now is basic supportive care for everyone. And for all the injunctive therapies,

I feel we have to be very careful that what we do is in evidence but also doesn't cause harm. And for that, I'm not aware of any drug at the moment, unfortunately, in this pandemic that has demonstrated strong evidence for its use.

MODERATOR: So, Maurizio, I said-- go ahead, Xuanze. You said you have a--

XUANZE: We, actually in China, we have quite a lot of data on that. We are writing paper. So this Friday we are finalizing all the data and finalizing the paper. Hopefully we can publish soon.

MAKE SPEAKER: OK. Very good. So no experimental therapies be it [INAUDIBLE] or chloroquine should be given outside clinical trial protocol at the moment. As soon as we learn more, we will move forward. I think everyone on this panel agree with that. OK.

You mentioned high flow [INAUDIBLE]. In a past life and we have a few cases here, we don't have proportions. It's seven, eight cases in the ICU at the time. So the high [INAUDIBLE] work, we used it for patients who are do not intubate and with some changes in position and time and God's will, one of our patients has gone just fantastic without intubation, with high [INAUDIBLE] despite severe [INAUDIBLE].

But experiences around the world seem to be different. Damien, I know you as a pessimist by profession and you don't want to intubate anyone that you have to. But it looks like that you had to intubated many more of these patients than you thought of before they came. Can you give us your impression?

DAMIEN: There's no magic bullet to prevent intubation. So far we, in France, have a long tradition of noninvasive treatments. So we use a lot high flow [INAUDIBLE] with some success. But we still intubate many patients. Probably too many patients.

There are some recommendations by a French society to say that when the patient has 6 liters of oxygen, we have to intubate. For me, it's a nonsense. We must hold on. And we see some patients who pass with high [INAUDIBLE] non-rebreathing mask for several days. And we managed to not to intubate them. We must really hold on to jump on the trachea [INAUDIBLE] and intubate.

MODERATOR: Thank you, Damien. I'm glad to hear it because I was scared to death. So maybe, Yaseen, I know you with MRSA, I don't know if you had COVID yet, you had a pretty bad experience contrary to other [INAUDIBLE].

Any thoughts of trying to do our old vision that you give some time to the patients because some of them and perhaps significant minority up to one third in normal times or 40% can survive obviously with less of a burden and then leaving the ventilator to those who have to have it, with sharp mental state and absolute indication.

So, Yaseen, what are your thoughts? I know that you just did not find it useful with MERS but any other thoughts? What is special about this pandemic care vs what is regular, other than having to put on protective equipment, so everyone is scared to be delayed?

YASEEN ARABI: Yeah. So thank you, Ogie. I think definitely some patient can be managed by oxygen as you mentioned and even they're critically ill and pull through. There are some subset of patients who are on the trajectory of getting worse.

And for our-- we had a paper for the MERS-CoV using noninvasive ventilation. And let me be specific here, using the face mask noninvasive ventilation. Using a mask of noninvasive ventilation. Not the helmet noninvasive ventilation. And the failure rate was so about third of the patients who are in respiratory failure were treated with noninvasive and 92% failed. 92%. So it is possible. I think one of the explanation for this is that these patient when you decide to put on noninvasive they are actually on the trajectory of getting worse. And it's just a [INAUDIBLE] storm. And a few hours later, they just get much worse. At the end of the day, mortality wasn't worse but they were more hypoxic when they failed.

Now, our colleagues in Italy, and I was on so many teleconferences and I think they're on the panel probably can give more insight, they're using a lot of helmet noninvasive ventilation. And we're waiting for a data. But apparently the results are better than the facial mask. But this will be really encouraging to use.

Part of it maybe because the ability to give higher positive pressure, higher positive pressure. So I don't know if other people have comments for the high flow nasal cannula. Again, I think it's surprising to me when I reviewed the many clinical trials being registered on all the trial registries how many drugs are being tested and how very few of aspects of support care is being tested.

So these fundamental questions of high flow noninvasive ventilation are-- they need to be tested. So high flow may be encouraging some patients. But the point is don't let the patient struggle for a long time before you decided to intubate. I think that's an important message whether noninvasive or high flow. Over.

MODERATOR: Maurizio and Dr. Wang. Maurizio first.

MAURIZIO CECCONI: Yeah, I think you're saying explained very nicely everything. I would like to add, we are gaining a lot of experience on NIVs, and especially helmets and CPAP in Italy. We're doing a study now, so it's too early to tell you will this would work or not. Often, you hear this question. Is it true that these patients come to the hospital and they are completely fine and then they collapse?

I don't know if it's Yaseen's experience or the others but my experience is that we are seeing so many patients that the clinical picture and the dynamics and the story of this patient can be so different. Somebody would come after four days of symptoms. Some after seven. Some after the ten. It's everyone is really different.

I would say don't use noninvasive ventilation if you've already decided that this patient will require intubation just to gain some time. That to me, it's a nonsense. However, we do find a group of patients that you put the patient on, they [INAUDIBLE], they speak to you, they seem to be able to get relief from the box here.

With these helmets, they find it a bit more comfortable because it's not pressing on their heads and on their face. And they can speak. Multiple features regarding the gastric pressure, it is true if you don't put the nasal gastric tube that's a risk. So to me it's not about the new things. It's about all the things that you normally do in your practice.

And choose the most simple way that works in your hospital and that everyone has used. Because you would find, at least what we found is that [INAUDIBLE] resources now that technology, of course, technology is not-- we don't have as much as before. But you do find ways to find technology. But the expertise to use the technology is what's really scarce. So we have great help from doctors from other specialties coming to help.

We have to create a level two intensive care unit. So we call this to be intensive care units or step down units for CPAP and other basic intermediate support in other words, that are managed of course with other colleagues that normally do not manage this. So in order to do that, we have announced our critical care outreach team, so that we go and we review the patients together at least twice a day.

We do see whether somebody is doing well with it. If somebody is not doing well with it, then you decide either based on goals of care or you don't lose time with an intubation. So I would say everyone is different. Do not use this support to avoid that intubation if you've already decided to intubate the patient. If you feel that the patient will require an intubation in a few hours, there's no point of getting extra time with a IV.

But there are certainly some patient that we see that they are getting relief. They're improving with it. Maybe they would improve it even without, but they're certainly getting a relief from it and we think in this moment getting some symptomatic relief is probably quite important when, as you were saying before, you don't have the time to be there all the time to hold their hands and speak with them maybe as you wanted to do before.

MODERATOR: Dr. Wang, and then David and Damien because this is really important. Dr. Wang, you wanted to say something.

MS. WANG: Yes. I want to emphasize the airway management of the patients. Because the way all of us emphasize the importance of the high flow oxygen therapy. But as a key point is that of humidity. Humidifier is very important. And then now I say to make the airway movement and then chest compress at the end of aspiration may be a good way to put a sputum outside.

And then another ways the positioning [INAUDIBLE], and then the aerosol therapy, and the high frequency oxygenation. And then we can do this procedure before and after the examining of the [INAUDIBLE] and then you can find out not only that they're high density may be, put it that way, after we finish this procedure.

So the key point is that if we want to prevent the patient including intubation, we have to make a mucoserous system in a good condition. So we have to think about all the procedures. To focus on how to maintain mucoserous system in a very good condition. So that's the key point. If we can do all the procedures in a very good way, and then, maybe, the opportunity to be intubated maybe low down.

MODERATOR: David and Damien, just any tricks with not intubating? Have you been successful not to intubate and what was the trick to do that?

DAVID KAUFMAN: Well, I will confess that I have not found that trick. Part of it is that at NYU, our triage system is set up so that we're able to take care of a lot of patients who are on high flow nasal or even CPAP outside of the ICU. So almost by definition, by the time they get to my care in the ICU, they've been intubated or they're about to be intubated.

On a couple of occasions, I've tried putting individuals in some other posture besides supine with the [INAUDIBLE]. So I've tried prone, left lateral, right lateral, decubitus. I've found that those patients generally have some temporary improvement in oxygenation but it's not a durable effect. And patients can't maintain those positions for a very long time and be comfortable.

I would say that very close to 100% of our patients in the ICU are intubated and on and receiving invasive mechanical ventilation. I would agree with everybody that the technique of innovation is extremely important. Trying to organize the team effectively to minimize the number of personnel who are present for what is going to be a highly aerosol generating procedure is crucial to the safety of everybody.

This is especially true because at NYU we're working in intensive care units where sometimes the nurses are not that experienced in taking care of mechanically ventilated patients. So we have to be really, really careful about how to divide up roles and who to have in the room at the time of intubation. And I think careful planning and having a team huddle before starting intubation is a crucial element of making sure your team is safe.

MODERATOR: Damien, do you have any other? I think we've saturated this. If you have to say something about preventing intubation, say it, but it looks like we've gone through this left and right and we have to intubate. So you have this skill. You have a fantastic team. You didn't use-- you hopefully were able to not to use bag and valve.

How do you deal with these patients? And I don't really particularly care if you're prone or not what do you do for your ideas during the ventilation sedation. And most interesting, how do you get them off the ventilator? Because the scary stories, someone get better, you extubate after third day and then you have to re-intubate and then they stay another seven days. And that's been like, you know, we had a patient here. [INAUDIBLE] like that. It's fine eventually, but this, first, hesitance. People are scared to extubate.

They are kicking the can down the road. You and I kind of-- lets the next shift deal with it or the next consultant. So what are you tricks or suggestions how to extubate these patients because it looks like this is a much bigger challenge that has ever been in AIBS. Our usual spontaneous breathing throughout extubation to see proper high flow nasal air if it is a high risk fluid balance.

All the things we've done, shallow breathing, whatever you have done previously worked and now it seems that it doesn't work. We [INAUDIBLE] kind of like in the 80s. But Damien, what do you do to excavate these people?

DAMIEN: Just in one word about intubation, maybe we'll talk about it later, but one of the striking features for this patient is that what some could say Silent hipoxia. With patients with low saturation. But waiting in our bed, playing with their phone, talking. I think this patient needs to be challenged. It can be challenged, managed, sorry, with noninvasive treatment.

They're important in this patient. We have, as Marie showed, we have level 2 ICU. Our level 2 ICU is full of patients. We've only noninvasive treatment. And I don't have statistics so far but many go through, and we do not need to send them and their Level 1 ICU to intubate them. But there are no statistics to give. Concerning extubation-- Yes?

MODERATOR: I just want to repeat it because I think it's important. So what I've heard is, really, if you can assemble your team well for intubation so that there are no delays in intubation. Then you could accept the risk the way you have accepted in the past.

Certainly everyone who has shock, other mental state, or other thing, getting worse on [INAUDIBLE] has to be intubated relatively quickly. But there's no reason to rush, if you are organized well. So you could have intubation team and putting the protective equipment lead team and everything is done in a speedy fashion that you would not be scared. So is that something that everyone would agree here?

Now you've intubated. So some of them will have to be intubated. And you'll sterilize them. They'll go through this primitive shock, whatever AP and hypoglycemia eventually gets better. I'm not going to talk about conjunctive treatments yet, but patients are improving somewhat. So the oxygenation is better and they are tolerating spontaneous breathing, yet they don't seem to be able to be extroverted the way we used to do that so what's going on?

DAMIEN: The-- what is difficult in this patient sometimes is winning of [INAUDIBLE]. In France maybe we used too much neuromuscular blockers, maybe we used too much point position. Maybe. I don't know.

But it quickly a vicious circle I think If we want to use a sedative for too long with these patients. So when they get well, we stop sedation but not enough stopping sedation. There we do it we carefully.

MODERATOR: I don't want to interrupt you because I think I get your point. So what you say, it's us not the disease that making it more difficult. It's always been like that. But if you're seeing even now with this disease is the same problem. The reason why they want me to wait is mostly the way we care for them. But other than the intrinsic unusual [INAUDIBLE]. Is that what you--

DAMIEN: I would say we are too much focused on the paO2/FI02 ratio. paO2/FI02 ratio is for the youngest ratio to make some steps. And it becomes an end point for treatment. I think it's not a good strategy. So I tolerate high FIO2. But we have to move on in the wake of the patient and try to extubate them even if we don't have a classical criterions for extubation. Of course, after that we use high flow nasal cannula very much.

MODERATOR: Extubation to high flow nasal cannula.

DAMIEN: Yes.

MODERATOR: David and then Chris. David, please. Wave to me. Yeah, just unmute yourself.

DAVID: Yeah, go ahead.

MODERATOR: So do you-- how do you extubate these people? Basically, do you agree with Damien that it's mostly us and maybe we could just do what we usually done to use the [INAUDIBLE]? Whatever someone has done to be able to move this quicker and extubate people quicker. Is there something special for you that you would advise us to do?

DAVID: Well in my n of four patients I've been able to intubate, one of which needed reintubation 48 hours later, I'm not sure I can say that I have detected a pattern. The three patients I was able to extubate successfully had several things in common. One, they were all pretty young. They were all under 60 years old.

So they probably had good neuromuscular reserves. Number two, we were very careful with their fluid balances. We eliminated unnecessary IV infusions like unnecessary antibacterials. I think it's a strong temptation to cover all of these folks with antibacterials. And that adds up to 750 milliliters a day. So we don't do that. We used diuretics judiciously.

And yeah, we pursued the same procedure that we would pursue with any other extubation. I've been using what I called dextubation a little bit more frequently where because a lot of these patients receive heavy sedation and then may be experiencing some withdrawal from opioids or benzodiazepines, we'll put them on a [INAUDIBLE] infusion, ensure that they're able to arouse easily and follow commands, sort of a rass of about negative one, and then we'll extubate while under the cover of [INAUDIBLE] to facilitate. No tricks. Just good clinical judgment.

MODERATOR: Thank you, David. Chris, you wanted to say something.

CHRISTOPHER FARMER: Yeah, mine is actually a question for the folks here that have had more experience with this. One of the things that is commented on is the increased incidence above what is normally expected for significant pulmonary hypertension.

And using medications to manage that has not been terribly effective and remitting the hypoxia seems to be the best way to lower the PA pressures and unload the right ventricle. Does that factor into any of the decisions regarding timing for extubation? Weaning and extubation for these patients?

MODERATOR: I don't know that anyone knows, but Dr. Peng, I don't know if we can hear you. He had the most experience with these patients. Peng Zhiyong can you unmute yourself? Can we hear you? Dr. Peng?

Maybe you try to get him to unmute. Dr. Peng, can you hear us? You had the most experience with these patients. So the question was about weaning and extubation and maybe some issues with pulmonary hypertension. Anything that you told me, I remember you told me that just like any other. Can you repeat this for everyone?

PENG ZHIYONG: So for extubation, we are pretty conservative compared to other areas. So if the people give a ratio that is above 250, and although we need to check chest X-ray or to see any improvement from the chest X-ray or CT. Also, we should be careful about the fluid balance.

MODERATOR: Thank you. Maurizio, yes, my thinking on that is like obviously you want to have some improvement in a disease and then reading criteria. But I'm not sure that necessarily you have to have the imaging findings to really go for that. I think maybe the risk, I'm not sure that that's proven outside these maybe studies. Maurizio, you wanted to say something.

MAURIZIO CECCONI: Yeah. Just to say I don't know about the incidence of pointing hypertension. We're doing some studies now. What I do know that this has to be treated as a bad pneumonia when it comes to the intensive care. If this was a single case we would not have so much stress to the system.

The reason why the we are under so much stress is because we have so many patients. However, even if we have so many patients, you need to be patient because these [INAUDIBLE], they do require to rest a bit.

And the only thing that we can do is to give the time for the patients to improve, basically. To fight with their immune system and to recover. Our data shows that we have an average length of stay in ICU of around 13, 14 days. So this is not a quick disease. This is something where every improve, they may improve after three or four days.

We see some young patients, you give them some rest, two, three days they seem to get better. However, some patient, there's treatment related after two weeks, maybe after three weeks. My message is that even if you are really stressed on capacity, again, on the same principle as before, this is about doing simple things well for a high volume of patients.

If you had only one patient, maybe you would wait an extra day or so. It's very difficult because the capacity is really an issue when you have a cluster outside. But if you give them time, a lot of patients can improve. We have to remember this is a very serious disease.

Mortality I think is around 26% from the whole ICU population. Now, maybe it will be even higher when we have a follow-up of more days because we are seeing more sufficient [INAUDIBLE] inside. It's a very serious disease. Even the ones that improve, they do require quite a bit of time on the ventilator. That's my experience.

MODERATOR: Yaseen?

YASEEN ARABI: Yeah, I just want to add that there is a lot of unknown about the [INAUDIBLE] involvement with COVID-19. So some of the area series suggested that cardiac causes are responsible for 30% of the deaths. Of course, this is based on a clinical criteria. So we don't know. Additionally, other series suggested that, or showed that up to 44 or 45% of patients have some type of [INAUDIBLE].

That's why they where in the ICU. So all of this together suggests maybe there's myocardial involvement. And we know from other viral infections, for example, the influenza, myocarditis, died myocardial depression, whether the right side or the left side of the heart can be involved.

So I think that's another factor when we think about extubation is how much myocardial involvement is there. Not a lot of histopathologic studies thus far. There is one I came across. And the myocardial was normal. But that's only n of one. And whether the myocardial involvement is related to the infection itself or relate to the cytokine storm, still unknown. But it appears that there is myocardial an involvement in this disease more so than what you would otherwise expect.

MODERATOR: So I like that-- and we'll get to that. We are getting to our last five minutes and I want to ask about experimental therapies and research in the last moment. I just want to get to this extubation thing. The part before this, when we used to use [INAUDIBLE] catheters to measure the [INAUDIBLE] pressures, nine out of 10 intubations where reintubations happen because the [INAUDIBLE] pressure went up to 40.