Lippincott Nursing Pocket Card - April 2024

Managing COVID-19 ARDS in Adults



Patients with severe COVID-19 pneumonia develop acute hypoxemic respiratory failure. While severely hypoxic COVID-19 patients meet the criteria for typical acute respiratory distress syndrome (ARDS), COVID-19 ARDS has unique characteristics. Unlike typical ARDS, COVID-19 ARDS may respond to steroids (Hornby, 2020), venous thromboembolism is more common, and there may be subtypes with differing lung compliance. The treatment of typical ARDS mainly consists of control of the primary etiology (infection, trauma, aspiration, etc.) and end-organ support. The treatment of COVID-19 ARDS includes antiviral, anti-inflammatory, and anticoagulant medications in addition to end-organ support. COVID-19 ARDS diagnosis and treatment guidelines are outlined below.

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.


Berlin Definition of ARDS

The Berlin definition of ARDS specify the following three criteria must be met:

  • Timing within one week of clinical insult
  • Presence of bilateral opacities not fully explained by effusions, lobar/lung collapse or nodules
  • Respiratory failure not explained by heart failure or volume overload (Matthay, 2021).

The severity of the ARDS is defined by the degree of hypoxemia, the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (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 

Interventions for COVID-19 ARDS

*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 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% to avoid oxygen toxicity.
  • 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 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 (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 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.
      • 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.
Alhazzani, W., Evans, L., Alshamsi, F., Møller, M. H., Ostermann, M., Prescott, H. C., Arabi, Y. M., Loeb, M., Ng Gong, M., Fan, E., Oczkowski, S., Levy, M. M., Derde, L., Dzierba, A., Du, B., Machado, F., Wunsch, H., Crowther, M., Cecconi, M., Koh, Y., … 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 medicine49(3), e219–e234.

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.

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.

Matthay, M., Thompson, T., Ware, L. (2021) The berlin definition of acute respiratory distress syndrome: should patients receiving high-flow nasal oxygen be included? Lancet Respir Med. Aug; ;9(8): 933-936.

National institutes of Health. (2021, December 16). Therapeutic management if hospitalized adults with COVID-19. 

RECOVERY Collaborative Group, Horby, P., Lim, W. S., Emberson, J. R., Mafham, M., Bell, J. L., Linsell, L., Staplin, N., Brightling, C., Ustianowski, A., Elmahi, E., Prudon, B., Green, C., Felton, T., Chadwick, D., Rege, K., Fegan, C., Chappell, L. C., Faust, S. N., Jaki, T., … Landray, M. J. (2021). Dexamethasone in Hospitalized Patients with Covid-19. The New England journal of medicine384(8), 693–704.

Siegel, M., & Hyzy, R. (2023, February 24). Ventilator management strategies for adults with acute respiratory distress syndrome. UpToDate.

Sonti, R., Pike, C. W., & Cobb, N. (2021). Responsiveness of Inhaled Epoprostenol in Respiratory Failure due to COVID-19. Journal of intensive care medicine36(3), 327–333.