Management in the ICU​

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• Management of severe COVID-19 in not different from management of most viral pneumonia causing respiratory failure (1)

• The principal feature of patients with severe disease is the development of ARDS: a syndrome characterized by acute onset of hypoxemic respiratory failure with bilateral infiltrates

• Evidence-based treatment guidelines for ARDS should be followed, including (1)

  • Conservative fluid strategies for patients without shock, following initial resuscitation (goal is to maintain a euvolemic to negative fluid balance)

  • Empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made

  • Earlier intubation and avoidance of NIV (High-flow nasal cannula, BiPAP) (2)

    • NIV should generally be avoided due to its unproven utility in patients with severe respiratory failure, ARDS, or a trajectory that suggests invasive ventilation is inevitable due to increased risk of virus aerosolization.

    • In such circumstances, patients should be transitioned from oxygen therapy via a simple facemask to intubation and invasive ventilation without delay. 

    • *Non-rebreather masks provide sub-optimal pre-oxygenation and promote aerosolization and are not recommended for this purpose. 

    • *Nasal oxygen therapy (via standard or high flow nasal cannulae) should not be used during pre-oxygenation or for apnoeic oxygenation due to the risk of virus aerosolization to the intubation team. 

  • Rapid sequence intubation should be used as the default technique unless there are concerns with the airway that make this inappropriate (2)

    • Airway assessment must show no signs of difficulty in intubation 

  • Lung-protective ventilation (Tidal volumes 6cc/kg) (3)

  • High PEEP strategies (Tables are available to guide PEEP titration based on the FiO2 required to maintain SpO2) (4)

  • Prone positioning (if P/F ratio persistently < 150) (5,6)

  • Consideration of extracorporeal membrane oxygenation (ECMO) refractory hypoxemia (salvage therapy) (7)

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References

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1. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. Published online March 11, 2020. doi:10.1001/jama.2020.3633

2. Brewster, D.J., Chrimes, N.C., Do, T.BT., et al., Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. The Medical Journal of Australia. Published online: 16 March, 2020, link: https://www.mja.com.au/system/files/2020-03/Updated%20PREPRINT%20SAS%20COVID19%20consensus%20statement%2017%20March%202020.pdf

3. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-77. Epub 2017/01/20. doi: 10.1007/s00134-017-4683-6. PubMed PMID: 28101605.

4. NHLBI ARDS Network Tools [website]. (http://www.ardsnet.org/tools.shtml, accessed 4 March 2020).

5. Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-68. Epub 2013/05/22. doi: 10.1056/NEJMoa1214103. PubMed PMID: 23688302. 

6. Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK. The pragmatics of prone positioning. Am J Respir Crit Care Med. 2002;165(10):1359-63. Epub 2002/05/23. doi: 10.1164/rccm.2107005. PubMed PMID: 12016096.

7. Combes A, Hajage D, Capellier G, Demoule A, Lavoue S, Guervilly C et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965-75. Epub 2018/05/24. doi: 10.1056/NEJMoa1800385. PubMed PMID: 29791822.

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