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
