Lippincott Nursing Pocket Card - February 2021

Managing COVID-19 ARDS in Adults

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Developed by Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN

Patients with severe symptoms of COVID-19 pneumonia often go on to develop acute hypoxemic respiratory failure and some will develop acute respiratory distress syndrome (ARDS) (Auwaerter, 2020). Critical care clinicians have managed ARDS for years; however, COVID-19 ARDS is different from the typical ARDS we’ve known.

COVID-19 in the ICU: Definitions

Severe COVID-19
Signs of pneumonia (fever, cough, dyspnea, tachypnea) plus one of the following:
  • Respiratory rate greater than 30 breaths/minute
  • Severe respiratory distress
  • SpO2 less than 90% on room air

Critical COVID-19
ARDS or respiratory failure requiring ventilation, sepsis or septic shock

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Berlin Definition of ARDS

The severity of the ARDS is defined by the degree of hypoxemia, which is calculated as the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2). ARDS can be classified as mild, moderate or severe based on the Berlin definition of ARDS (Ranieri et al., 2012).

 
Berlin Definition of ARDS (Ranieri et al., 2012)
ARDS Severity PaO2/FiO2 Ratio
Mild 200-300
Moderate 100-200
Severe <100
*on positive end-expiratory pressure (PEEP) ≥ 5 cm H2O
 
It is important to remember that certain variables may impact the PaO2/FiO2 ratio, including:
  • Chest x-ray severity
  • Respiratory system compliance
  • Positive end-expiratory pressure (PEEP)
  • Corrected expired volume/minute

Lung Compliance

The ability of the lung to expand and recoil is compliance. When comparing traditional ARDS to COVID-19 ARDS, lung compliance is very important. Compliance can be divided into two types:
  • Static compliance – lungs not moving and at rest (pressure is the only variable)
  • Dynamic compliance – lungs moving during breathing
Certain disease processes affect lung compliance, by either decreasing or increasing compliance:
  • Low lung compliance
    • Pulmonary fibrosis, due to collagen build-up which decreases lung elasticity
    • ARDS, due to atelectasis in dependent areas of the lung
  • High lung compliance
    • Chronic obstructive pulmonary disease and emphysema, due to elastic recoil damage
    • COVID-19 ARDS (Gattinoni et. al., 2020)

Interventions for COVID-19 ARDS

Follow the Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) and the First Update (January 2021).

*Perfusion is equally as important as ventilation.
  • 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 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 1st 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.
  • 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 paralyzing the patient.
  • Patients decompensate quickly, especially during weaning; use a very, very slow weaning process even if patient appears comfortable on low pressure support (PS) settings.
  • Patients are coagulopathic; if using continuous renal replacement therapy (CRRT), consider frequent boluses of heparin versus infusion, or administration of argatroban 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)
    • Strong recommendations
      • Avoid using hydroxychloroquine.
      • Use a short course of systemic corticosteroids over not using corticosteroids.
      • Administer pharmacologic VTE prophylaxis.
    • Weak recommendations
      • For patients considered for corticosteroids, use dexamethasone over other corticosteroids.
      • For adults with severe COVID-19 who do not require mechanical ventilation, IV remdesivir is suggested and should be started within 72 hours of positive PCR or antigen test.
      • For adults who require mechanical ventilation for critical COVID-19, IV remdesivir is not suggested.
      • For adults with severe or critical COVID-19, it is suggested that convalescent plasma not be used outside of clinical trials.
References:

Alhazzani, W., Møller, M. H., Arabi, Y. M., Loeb, M., Gong, M. N., Fan, E., Oczkowski, S., Levy, M. M., Derde, L., Dzierba, A., Du, B., Aboodi, M., Wunsch, H., Cecconi, M., Koh, Y., Chertow, D. S., Maitland, K., Alshamsi, F., Belley-Cote, E., Greco, M., … Rhodes, A. (2021). Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update. Critical care medicine. https://www.doi.org/10.1097/CCM.0000000000004899

Alhazzani, W., Møller, M. H., Arabi, Y. M., Loeb, M., Gong, M. N., Fan, E., Oczkowski, S., Levy, M. M., Derde, L., Dzierba, A., Du, B., Aboodi, M., Wunsch, H., Cecconi, M., Koh, Y., Chertow, D. S., Maitland, K., Alshamsi, F., Belley-Cote, E., Greco, M., … Rhodes, A. (2020). Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Critical care medicine48(6), e440–e469. https://doi.org/10.1097/CCM.0000000000004363

ARDS Definition Task Force, Ranieri, V. M., Rubenfeld, G. D., Thompson, B. T., Ferguson, N. D., Caldwell, E., Fan, E., Camporota, L., & Slutsky, A. S. (2012). Acute respiratory distress syndrome: the Berlin Definition. JAMA, 307(23), 2526–2533. https://doi.org/10.1001/jama.2012.5669

Auwaerter, P. (2020). Coronavirus 2019: COVID-19. Johns Hopkins POC-IT Guide. Unbound Medicine. Updated April 2020.

Gattinoni, L., Coppola, S., Cressoni, M., Busana, M., Rossi, S., & Chiumello, D. (2020). COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. American journal of respiratory and critical care medicine, 201(10), 1299–1300. https://doi.org/10.1164/rccm.202003-0817LE

Siegel, M., & Hyzy, R. (2021, January). Ventilator management strategies for adults with acute respiratory distress syndrome. UpToDate. https://www.uptodate.com/contents/ventilator-management-strategies-for-adults-with-acute-respiratory-distress-syndrome