We have reuse of N 95 but generally rotate the masks every 3-4 Days. by the end of that period, any viral contamination is likely dead.

#ATSchat A1 We also have a dedicated room for intubation that is negative pressure, even if we run out of negative pressure rooms for all patients We also put a surgical mask OVER the N95 to catch large particles and droplets, and further preserve the life span of the N95

Once community spread began, we converted to almost all video visits, but this may have a downside of limited face to face contact and exam of patients

#ATSchat A2. We use chloroquine, azithromycin (but some have QTC prolongation so need to monitor). Tylenol , maybe regularly and not prn for fever No NSAIDS (weak data) trial of remdesivir Consider Tocilizumab for cytokine storm, but a trial being done of IL6 antagonists

Not everyone gets up front. Use procalcitonin and may hold if low. Also for VAP, may recognize from serial procalcitonin rise.

#ATSchat A2 We are doing a lot of proning and this seems effective, but labor intensive, so we are using physical therapists to work as a "proning team" For vent shortages, we are considering using transport vents for patients who are recovering

#ATSchat A2 We are NOT using steroids routinely and only if a specific non-COVID indication It seems that many patients will have prolonged vent, maybe 2 weeks , before extubation , so need to be prepared, and thus maybe a role for transport vents later in the course

#ATSchat A2 Intubation with RSI protocol NO bag valve mask Go from intubation , right onto vent.

With many patients needing 2 weeks of vent and the trach being an aerosol generating procedure, we are probably going to individualize but tend to wait.

#ATSchat Its all hands on deck We have anesthesiologists, surgeons, and other critical care certified pateints taking care of these patients, with PCCM consultation We need to "extend" our PCCM staff by having them work in teams with others.

#ATSchat A3. We also have minimized PCCM care of non-COVID patients, letting other intensivists do this. We are forming teams with PCCM, hospitalists, residents and fellows, so again we get the most from our PCCM staff.

#ATSchat A3. Video monitoring of inpatients is a way to minimize the entering of rooms and the risk and burnout of staff. Still need to be in the room sometimes, but plan this and minimize the number of the staff going in the room.

#ATSchat A3 Specialized teams do what PCCM normally does. We have a dedicated team (anesthesia) to do intubation and they carry all the PPE and intubation devices We have a surgical team that does central lines We have a team of physical therapists to prone

#ATSchat Good plan, but when the surge happened for us, this was not possible and if it continues to surge we need to be innovative.

#ATSchat A4 Please see our editorial , now on line from Am J Respir Crit Care Med this week Has an agenda for research

#ATSchat A4. Some research priorities Defining host and viral virulence factors that can predict and explain which patients are likely to have mild or severe disease, and by what mechanism -- Define viral incubation period and the optimal duration of quarantine

#ATSchat A4 Other priorities are: Identify common medications that might alter disease susceptibility and outcome; aspirin and non-steroidal anti-inflammatory agents, ACE inhibitors and receptor blockers: agents that could alter cellular binding sites for the virus

#ATSchat A4. We would also like to know how much herd immunity will be needed to slow pandemic spread -can we develop biomarkers or clinical tools to predict disease course and severity

#ATSchat A4 Interesting areas are also Toools to improve patient management, allowing effective isolation and monitoring (e.g. telemonitoring in home or in residential facilities) --Define methods to allow for non-invasive ventilation without risking harm to healthcare workers

#ATSchat Great question. If we use ARDS as a model the long term prognosis may not be terrible, but it may take time to reach a good baseline.