This is good, and I'm glad they're doing it. They've clearly got involvement with existing ventilator manufacturers. Are they talking to doctors in ITUs? Her

This is good, and I'm glad they're doing it. They've clearly got involvement with existing ventilator manufacturers. Are they talking to doctors in ITUs? Here's a recent Facebook thread from people involved in London's new hospital: https://www.facebook.com/permalink.php?id=103930280957826&story_fbid=217689892915197 https://www.facebook.com/permalink.php?id=103930280957826&st... It shows that ventilation of covid-19 patients is not like ventilation of other patients. I'll paste part of it here because I know some can't visit Facebook. It's by Daniel Martin OBE, Macintosh Professor of Anaesthesia, Intensive Care Lead for High Consequence Infectious Diseases. ---everything below this point is a direct quote from Daniel Martin--- Ventilation - Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness. - Avoid spontaneous ventilation early in ICU admission as also may be harmful. - There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space. - Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related. - Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation. - Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT. - Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier. - Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting. - Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days. - Generally people are using humidified circuits with HMEs. - A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily. - Leak test before extubation is crucial, others are also seeing airway swelling. - Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high. My conclusions from this are: - Less aggressive PEEP strategy at the beginning of the disease and go straight for proning. - Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky. - An extubation protocol is needed immediately. - We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.