Okay so let's sum up if you have a patient that comes in with respiratory
symptoms GI symptoms and constitutional symptoms and respiratory symptoms
remember is chest pain Disney on exertion shortness of breath GI symptoms
could be nausea vomiting or diarrhea abdominal pain constitutional symptoms
will be fevers night sweats or chills and on x-ray the patient has infiltrates
and on CT ground-glass opacification or dense infiltrates bilaterally
dependently and they vaped in the last 90 days then you've got to be thinking
about this possible situation with the epidemic that we've been talking about
and then the question is is this confirmed versus probable so what you
really have to do at that point is you've got to rule out pulmonary
infection and the way you would do that of course is by getting some of your lab
tests that you would normally get you want to get a respiratory viral panel
these are panels where you can check for very small amounts of the viral DNA in
the patient's nasal swab that'll also check for the influenza PCR this is
particularly important if you're looking at cases between October and April
because that's when the flu is rampant you also want to get a urine antigen for
strep and a urine antigen for Legionella also as we mentioned sputum cultures
blood cultures also check for HIV remember though it's good to be a little
bit problematic because your WBC is in the study 87% of them had greater than
11,000 some of them were as high as 20,000 and there was definitely a
neutrophil yet which would lead you to believe that perhaps these patients
actually have bacterial infections what's even more problematic is that the
procalcitonin levels in these patients on average were 0.58 and depending on
where those tests are being done for the most part anything less than 0.1 is
negative so you're going to have a positive procalcitonin in a lot of these
patients you're gonna have neutrophilia and your white counts going to be
elevated and so you're going to suspect that this patients has a pneumonia so
even if they do have a pneumonia but you don't feel like the patient's pneumonia
adequately explains the severity of their illness you could consider that as
a probable case but if all of this is all negative and you have everything
over here on the left hand side the CDC and also for the intended purposes of
the study considered this as a confirmed case and now finally we come to
treatment which is problematic because we have no randomized control trials
this is a new epidemic this is a new problem we don't know what's really
working here and so there are no official guidelines and so this is an
important point that I want to make is that we really can't have any
recommendations and that was not the purpose of this paper that was published
in the New England Journal of Medicine however they were able to see what
treatments were used and also the fact that only one person died in the study
so that was about 2% of the study so in looking over what they did for these
patients and if you look at the study you'll see that of course supportive
care is big right so the patient stops vaping they stop using e-cigarettes and
you support them during this process with supplemental oxygen with sometimes
even ventilators so they have to be intubated and for those people who are
mechanically ventilated it was seen in some of the case studies in that report
that they were treated as if they had a RDS and because some of them actually
met the criteria the Berlin criteria for a RDS which is a severe a RDS which
would be APF ratio of less than 100 moderate would be less than 200 and then
mild would be less than 300 and so the treatment in those situations would be
low tidal volumes and so you're looking at starting out at 8 MLS per kilogram
ideal body weight and then going down to a target of 6 in some of these cases
proning them I think there's a study out of France that showed that if the
if ratio was less than 150 that the patient benefited from proning also
paralysis some studies have shown that paralysis early on can improve in
survival and so treating the patients like we would normally treat them
regardless of the cause is still something that is worthwhile doing the
interesting point though is what a lot of people have been finding some success
with although it's anecdotal and again let me reintroduce steroids and with
high-dose steroids we're talking for instance solu-medrol 125 milligrams IV Q
6 or the usual dose that you might do in someone with diffuse alveolar hemorrhage
is up to one gram of solu-medrol a day in which case it would be 250 milligrams
IV q 6 the problem of course with giving high-dose steroids indiscriminately is
that you've got to really make sure and be confident that the patient doesn't
have an overwhelming infection and that is sometimes problematic in a patient
who has a high white count and maybe has a band amia or maybe has a neutrophilia
so this is something that has to be entertained with some thought before you
just go rushing in there with high-dose steroids nevertheless these patients who
did well we're started on high-dose steroids and that's something that is
notable and you can check that out in the article then the other question is
whether or not to give antibiotics and of course you've got to be pretty
confident that there is no infection but if you are gonna start antibiotics
because you might think that there's an infection of course follow the
guidelines for your area again remembering that you want to start
broad-spectrum antibiotics that we'll cover for the most likely causes of
pneumonia in your patient population so this is something that is evolving and
hopefully we'll be able to get more information about this epidemic of e
cigarettes and vaping currently thanks for joining us