COVID-19 vaccines: medical concerns and recommendations

[45dotACP]

Can't say that I thought about using incentive spirometry. I might have to think about that one. However I am an absolute big fan of pulmonary rehab for this. I've asked how we had people to try to keep track of how many we have and maybe we can do a paper or something in the future.

At this point it's about all we have. Primary Care keeps sending patients over thinking we've got some miracle drug that's going to reverse their fibrosis. Maybe they'll come up with one in the future.

My personal experience mirrors what @Nephrology mentioned, many patients have Improvement but quite slow, especially compared to standard ARDS. Months and months of recovery. And then there is a subset of people who just will not get better at all.

I feel like I ought to clarify, I give the IS for patients mostly in the inpatient unit in which I'm a nurse. I am a big fan of not losing recruitment in patients that have poor mobility because of really bombed out stamina secondary to hypoxia.

(We also use mechanical lifts to put patients up to the chair if they can't do it themselves and self prone patients who can)

The utility of IS in preventing atelectasis aside, it also allows patients to feel they are able to do something to improve their recovery, which is big when you're going to be in the hospital for months at a time with no visitors.

The other major challenge we face is nutrition, given that patients breathing 40rpm can't really chew much and it seems to mess with their swallowing. Often our doctors will suggest NGT placement and tube feeds if our patients have been consistently consuming less than 50% of their meal tray for multiple days. The real problem there is that it's tricky to place an NGT on someone whose respiratory status is so fragile, and you REALLY want to avoid causing a pneumo.

My colleagues have become very good at NGT placement, and we've been using a bedside NGT with a camera implanted that will allow us to visualize the inside of the stomach and verify that we aren't in the airway.

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[4RNR]

The other major challenge we face is nutrition, given that patients breathing 40rpm can't really chew much and it seems to mess with their swallowing. Often our doctors will suggest NGT placement and tube feeds if our patients have been consistently consuming less than 50% of their meal tray for multiple days. The real problem there is that it's tricky to place an NGT on someone whose respiratory status is so fragile, and you REALLY want to avoid causing a pneumo.

My colleagues have become very good at NGT placement, and we've been using a bedside NGT with a camera implanted that will allow us to visualize the inside of the stomach and verify that we aren't in the airway.

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Stupid question. Isn't there a IV nutrient thing?!?

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[Stephanie B]

To be honest when I am outside breathing freely circulating air I never worry about COVID at all, don't wear masks outdoors for this reason. I am sure there is some % chance of getting COVID from someone I am sharing a hiking trail with but after 3 vaccines and with quasi-infinite dilutional volume for their expired air, it is surely fairly low.

Sharing indoors spaces is a different calculus, but I don't think COVID should make you feel as if you cannot bike/hike/walk the dogs.

How about indoor ranges? Does the ventilation flow reduce the risks? (Apologies if this has been covered already.)

[HeavyDuty]

How about indoor ranges? Does the ventilation flow reduce the risks? (Apologies if this has been covered already.)

I thought long and hard about that, and choose to wear a KN95 at indoor ranges unless I’m alone or close to it - from my conversations the demographics of shooters are biased towards the unvaccinated.

[TGS]

How about indoor ranges? Does the ventilation flow reduce the risks? (Apologies if this has been covered already.)

I thought long and hard about that, and choose to wear a KN95 at indoor ranges unless I’m alone or close to it - from my conversations the demographics of shooters are biased towards the unvaccinated.

Remember the study from last year about covid risk inside aircraft being insanely low due to the effective circulation of air?

IIRC, aircraft have an interior flow rate of 10-20cfm per seat. NIOSH minimum for a shooting line is 50cfm, ideally 75cfm. Whereas the airflow on an aircraft is from top to bottom, airflow on a proper range is downrange....meaning when you exhale, everything is going forward of your booth, not dispersing side-to-side to other lanes....especially since most indoor ranges have physical dividers between lanes.

Covid on a properly ventilated shooting range is basically a non-issue, imo. The measures for making it safe to shoot make it safe for covid and other airborne clouds of nasties.

[Stephanie B]

Remember the study from last year about covid risk inside aircraft being insanely low due to the effective circulation of air?

IIRC, aircraft have an interior flow rate of 10-20cfm per seat. NIOSH minimum for a shooting line is 50cfm, ideally 75cfm. Whereas the airflow on an aircraft is from top to bottom, airflow on a proper range is downrange....meaning when you exhale, everything is going forward of your booth, not dispersing side-to-side to other lanes....especially since most indoor ranges have physical dividers between lanes.

Covid on a properly ventilated shooting range is basically a non-issue, imo. The measures for making it safe to shoot make it safe for covid and other airborne clouds of nasties.

So, OK to not wear a mask on the lane, but if shooting an indoor USPSA/IDPA match, mask up?

[Sensei]

No, the IS is good for popping open lungs that have collapsed at the bases for whatever reason (often due to shallow respirations caused by pain, pain meds, whatever) but fundamentally the pulmonary fibrosis is a consequence of the peculiar hyper-inflammatory nature of the immune response to COVID infection in certain individuals. Recruiting your bases with the IS won't do anything to change that.



Hah well I am still in training so my pay comes in the form of a bonus called "the gift of education." Will be that way for a while longer...



It's super important in the inpatient context no doubt, atelectasis superimposed on baseline reduced pulmonary reserve is a bad situation and patients de-recruit easily when they're supine in a hospital bed most of the day. I just don't have any reason to think in the long term it will affect the pathophysiology of post-COVID fibrosis as fundamentally it is driven by the peculiar immune response to this virus specifically.

About 50-60% of my thesis was about fibroproliferative ARDS; my first author paper from this work was published online the week that COVID became headline news in USA (mid March 2020). At the time, the concept of post-ARDS fibrosis was fairly controversial and had received little attention in medical literature as it was subtle and equivocal. While many patients in post-ICU clinics were observed to have reduced lung function after ARDS, it was hard to say definitively whether that was a true new deficit or if there was some degree of baseline resp insufficiency that had evaded clinical attention, or if there was a component of MSK involvement affecting ventilation, or whatever. Fairly controversial whether or not it really existed.

It is really bizarre now, almost 2 years later, to see it commonly and in such a large % of the patients I am seeing in clinic. Of the ~120-150 patients I've seen in the last 4 weeks, probably 20 or so of those visits were post COVID PNA ED visit +/- admit, all of them with some degree of residual deficit, satting 92%ish @ check in, down to mid 80s when I ambulate them on the monitor, listen to them tell very similar stories while I put in order for Home O2 in CPRS... Pretty weird experience.

At least in the post-operative patient, the evidence for improved outcomes behind IS alone is very weak. It doesn’t cause harm which is why I do it. However, I often roll my eyes every time I hear a nurse or surgeon threaten patients with death by pneumonia if they do not religiously use their IS.

[Borderland]

I thought long and hard about that, and choose to wear a KN95 at indoor ranges unless I’m alone or close to it - from my conversations the demographics of shooters are biased towards the unvaccinated.

You can kill the unvaccinated. More than likely they can't kill you if you're vaccinated. I don't wear a mask when I shoot because I shoot outside and the range is deserted these days anyway.

Yeah, I'm going with 50/50 vax rate for range shooters. But I'm vaccinated so I'm not too worried about it. Not my problem.

[HeavyDuty]

Remember the study from last year about covid risk inside aircraft being insanely low due to the effective circulation of air?

IIRC, aircraft have an interior flow rate of 10-20cfm per seat. NIOSH minimum for a shooting line is 50cfm, ideally 75cfm. Whereas the airflow on an aircraft is from top to bottom, airflow on a proper range is downrange....meaning when you exhale, everything is going forward of your booth, not dispersing side-to-side to other lanes....especially since most indoor ranges have physical dividers between lanes.

Covid on a properly ventilated shooting range is basically a non-issue, imo. The measures for making it safe to shoot make it safe for covid and other airborne clouds of nasties.

I’m an analyst. My reasoning is that people behind me are going to be exhaling into airflow that is being sucked downrange though my booth.

You can kill the unvaccinated. More than likely they can't kill you if you're vaccinated. I don't wear a mask when I shoot because I shoot outside and the range is deserted these days anyway.

Yeah, I'm going with 50/50 vax rate for range shooters. But I'm vaccinated so I'm not too worried about it. Not my problem.

Outdoor shooting is my preferred solution, too - unmasked.

[TGS]

I’m an analyst. My reasoning is that people behind me are going to be exhaling into airflow that is being sucked downrange though my booth.

I'm not telling you what to do, and I don't know what your range is like......but let's analyze then:

My range is 15-20 feet from the line to the back wall, so I've got 10+ feet of distance between me and anyone crossing my lane behind me, with even better ventilation than an airplane which increases diffusion even more.

So, I think it's entirely reasonable to unmask on the firing line, especially since most people are wearing a mask and not an N95, meaning whatever hits us at 6+ feet isn't going to be protected from by the mask to begin with.

Again, look at the insanely low risk of contracting covid on an airplane which is exponentially more packed than even a busy and cramped gun range. Distance create diffusion, ventilation increases the rate of diffusion, and we're talking a small fraction of population density compared to an aircraft...I could ask my ex who is an industrial hygienist with a ventilation class under her belt to do the math, but I'd danger a guess that being 10 feet away from someone inside a gun range is probably akin to being 30 feet away from someone inside a building with standard ventilation.

So, wear an N95 if you want, but if you feel an N95 is needed on the firing line then you should probably be wearing an SCBA everywhere else in life due to the comparative risk at said venues lacking what an indoor range offers (unless you do your 8 hour workday inside a wind tunnel, that is).