Interventions for COVID-19 ARDS

Intubation Management

*Perfusion is equally as important as ventilation, and patients who are mechanically ventilated for COVID-19 ARDS often require prolonged ventilation periods for two weeks or more. 

• Intubate and extubate in a negative pressure room; staff should don appropriate personal protective equipment (PPE), preferably Powered Air Purifying Respirators (PAPRs); minimize number of staff in room.
• Use a low tidal volume (Vt) strategy; Vt 4-8 mL/kg of predicted body weight (most common 6 mL/kg).
• Target plateau pressure of less than 30 cm H₂O; higher levels significantly increase the risk of barotrauma.
  • If plateau pressure is greater than 30 cm H₂O, decrease PEEP or decrease Vt.
• Use FiO₂, PEEP, and Vt to oxygenate the blood and ventilate the patient.
  • In mild ARDS, can start with lower PEEP.
  • In moderate to severe ARDS, consider higher PEEP strategy (10 cm H₂O or greater).
• Maintain SpO₂ no higher than 96% to avoid oxygen toxicity.
• Assess patient response to low tidal volume ventilation within the first four hours of ventilation. Consider obtaining an arterial blood gas to measure PaO₂:FiO₂ ratio.
  • If PaO₂:FiO₂ is greater than or equal to 150 mm Hg continue low tidal volume ventilation
  • If PaO₂:FiO₂  less than 150 mm Hg consider pronating patient if possible.
• Consider alternative modes of ventilation, such as pressure-limited modes or volume targeted pressure-controlled ventilation (remember, compliant lungs need less pressure).
• Use recruitment maneuvers; avoid using staircase (incremental PEEP) recruitment maneuvers.
• Early proning for mechanically ventilated adults with COVID-19 ARDS
• • Consider proning  for 12-16 hours/day and repeat daily until no longer needed or there is no response.
  • If improvement is seen with prone sessions, consider weaning FiO₂ and PEEP.
  • Watch for hemodynamic and ventilation/perfusion instability for 1^st hour post-proning and placing patient supine.
  • Proning results take longer to see than typical ARDS; results are more due to redistribution of perfusion and gravitational forces (Gattinoni et al., 2020)
  • Put cables and intravenous lines on one side, when possible.
  • If available, use a proning team (an experienced group of critical care nurses and respiratory therapists.) Some facilities require a critical care or anesthesia provider to be nearby in case of disruption of the endotracheal tube.
• Inhaled pulmonary vasodilator therapy (e.g., inhaled nitric oxide)
  • Utilized as a trial of rescue therapy.
  • Has been shown to provide a modest, transient improvement in oxygenation without any improvement in mortality or duration of ventilation.
  • If no rapid improvement in oxygenation, taper the treatment.
• Sedation
  • When proning, patients may require additional sedation to tolerate the prone position.
  • If patients continue to have ventilator dyssynchony despite optimizing ventilator settings and sedation, consider using a neuromuscular blocking agent.
• Patients decompensate quickly, especially during weaning; use a very, very slow weaning process even if patient appears comfortable on low pressure support (PS) settings.
• COVID-19 is associated with a hypercoagulable state; if using continuous renal replacement therapy (CRRT), consider frequent boluses of heparin or an infusion pre-circuit.
• Consider tracheostomy if the patient is anticipated to be on the ventilator for over 14 days and if oxygen requirements allow. This is a highly aerosolized procedure so perform it in a negative pressure room. Consider trach teams if the volume of tracheostomies is high.
• In mechanically ventilated patients with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, attempt veno-venous extracorporeal membrane oxygenation (ECMO), if available, or refer the patient to an ECMO center. ECMO should only be considered for select patients with COVID-19 and severe ARDS.
• Pharmacotherapy (Alhazzani et al., 2021; NIH, 2021)
  • Strong recommendations
    • Use a short course of systemic corticosteroids and start early in disease course (within 14 days of onset). Conversely, avoid corticosteroids in patients who have persistent   ARDS beyond 14 days, as their use may increase mortality in this setting.
    • Administer pharmacologic venous thromboembolism (VTE) prophylaxis; if the patient develops a deep vein thrombosis (DVT), place on therapeutic anticoagulation unless there are contraindications. Intermediate anticoagulation dosing is not recommended except in a clinical trial.
  • Moderate recommendations
    • For patients on oxygen and considered for corticosteroids, use dexamethasone over other corticosteroids; if dexamethasone is unavailable, can use prednisone, methylprednisolone or hydrocortisone.
    • Evaluate hospitalized patients on supplemental oxygen with rapidly increasing oxygen needs for emergency authorization use of baricitinib or tociluzimab; do not use the two drugs together except in a clinical trial.
    • Evaluate hospitalized patients requiring oxygen for remdesivir therapy.
    • Consider a trial of epoprostenol nebulized therapy for intubated and mechanically ventilated patients who continue to be hypoxic despite other interventions (Sonti et al., 2021).
    • For adults with severe or critical COVID-19, it is suggested that convalescent plasma not be used outside of clinical trials.
  • Weak recommendation
    • If the patient is in septic shock, use a conservative versus liberal resuscitation therapy with a buffered crystalloid solution.