Interventions for COVID-19 ARDS

• 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 needed 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%.
• 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.
• Proning for mechanically ventilated adults with COVID-19 and ARDS
  • Consider 12-16 hours/day.
  • 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.
• Avoid the use of inhaled nitric oxide.
• For patients who remain hypoxemic despite optimizing ventilation and other rescue strategies, attempt a trial of inhaled pulmonary vasodilator as a rescue therapy. 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.  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 over not using corticosteroids.
    • 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.