Michael Niederman, MD, on How I Practice Now: Inpatient vs Outpatient Management Challenges

In this video, Pulmonology Consultant Advisory Board Member Michael Niederman, MD, from Weill Cornell Medical College, talks about the challenges that pulmonary and critical care physicians may face when treating inpatients and outpatients during the COVID-19 pandemic and how they can be overcome.


Michael Niederman: Hello, I'm Dr. Michael Niederman, professor of clinical medicine and associate chief of pulmonary and critical care medicine at Weill Cornell Medical College and NewYork Presbyterian Weill Cornell Medical Center.

I'm very interested to talk to you today about COVID-19 and some of the challenges that we're facing in pulmonary and critical care. Pulmonary and critical care physicians are at the front line of dealing with this disease, both because we commonly deal with pneumonia and because we're the individuals who work in the ICU. And the challenge in our division of pulmonary and critical care is to continue to maintain the management of our complex outpatients, field questions about pneumonia and COVID-19 and, at the same time, provide care for the very sick inpatients in the hospital, in the ICU, particularly the many who need mechanical ventilation.

To face this challenge, we've—at least initially—divided up our team into a group of people who are primarily specializing on inpatient care and a group who are specializing on outpatient care. And it's likely that many of us will rotate back and forth. It's important that we provide both, and it's emotionally draining—particularly on the inpatient side, but as well the outpatient side. 

We're using video visits primarily for our outpatients, and we're also working to some extent with video ICU care for some patients in the hospital, at least providing consultation via video to some of the teams.

In terms of management, again, I think there's a huge difference between what's recommended in inpatients and outpatients. And what I see, which I'm not very happy about, is that a lot of the inpatient ideas are being extended to outpatients. So for example, I don't think that hydroxychloroquine has been shown to be preventive. I don't think people should be taking it routinely when they're not even sick. Similarly, if they have mild illness, I don't think that it's probably something worth doing. And the other thing that I've heard about is people taking both hydroxychloroquine (Plaquenil) along with azithromycin, and that's something we might do in the hospital. But when we do it in the hospital, we do it with very careful cardiac monitoring to look for QT prolongation, and the combination of hydroxychloroquine and azithromycin can prolong QT interval. So if you're doing this as an outpatient without a very good indication and you're not getting cardiac monitoring, then there's certainly a risk of developing QT prolongation and cardiac arrhythmias.

I do think as an outpatient, one of the principles of management is control of fever. And currently, it appears as though Tylenol is a better choice than some of the NSAIDs. So I think that people ought to stick with Tylenol as the major way of controlling fever. I think that if patients get in the hospital, there are a number of other therapies we do. We are using hydroxychloroquine, but again, another caution I would give to outpatients is there are a number of people, particularly with lupus and other connective tissue diseases, who rely on Plaquenil, hydroxychloroquine, to control their disease. If people start buying it up and using it instead of those medications being available for patients with the rheumatic disease and they're using it, patients who truly need this medicine may not be able to get it.

Getting back to the inpatient side, we are using hydroxychloroquine; if there's an infiltrate we're using antibiotics for pneumonia. And then we’re doing primarily supportive care and a number of clinical trials. Drugs that are being considered are remdesivir, which is either being done in a clinical trial or on compassionate use. And then other drugs that might be valuable, but clearly depends on clinical trial data and will clearly depend on the timing in which they’re administered, is something like corticosteroids, which, at least for influenza, leads to increased mortality because it slows viral shedding and increases the rate of nosocomial infections. Right now, we don't know that corticosteroids ought to be used in this disease. However, there are some nuances that need to be worked out, and maybe later in the disease—after infection control and uncontrolled inflammation—it might have value. Some preliminary data from China suggested potential value. There's also IL-6 antagonists and other anti-inflammatory medications. But again, these are primarily directed at patients who have uncontrolled inflammation, and the timing and the selection of patients for this still needs to be worked out. And so there are clinical trials for that purpose. 

One last medication concept I'll mention is that there's been some controversy about ACE inhibitors and angiotensin receptor blockers. That's because these drugs may interact with the binding site for coronavirus on the cell surface. There’s been some speculation that these drugs could make patients more susceptible and more sick—other speculation suggesting that they may be beneficial. I think that—at least the official recommendation right now that’s been published in Europe and here in the United States is—anybody who's on these medicines should not stop them. But on the other hand, people should not start them. And there are anecdotal reports, and I think we need to see real data before we accept them: that patients are on these medicines may actually be less likely to get infected and may have a milder course of illness. But again, that's purely anecdotal until we see real date on that I would not recommend anybody rely on that.

So that's a couple of my thoughts about dealing with coronavirus and the problems that we're facing. I know that this is going to be challenging for all of us, and I hope that we'll have better times in the future to talk about this and other topics. Thank you.

For more on COVID-19, visit COVID-19 Care360.

Michael S. Niederman, MD, is associate division chief and the clinical director of the Pulmonary and Critical Care Medicine at the NewYork Presbyterian-Weill Cornell Medical Center. He is also a professor of clinical medicine at Weill Cornell Medical College.

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