Intensive care medicine

2019-20 coronavirus outbreak

Emergency medicine

Extracorporeal membrane oxygenation

Health care

ARDS

Respiratory distress

Betacoronavirus

Virology

Personal protective equipment

Economics

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Anesthesia

Outbreak

Coronavirus disease 2019 (COVID-19)

Acute respiratory distress

Pediatrics

Political science

Respiratory failure

Infectious disease (medical specialty)

Internal medicine

MEDLINE

Coronavirus Infections

Respiratory system

Medicine

Economic growth

Pandemic

Disease

Lung

The Lancet Respiratory Medicine

In The Lancet Respiratory Medicine, Kollengode Ramanathan and colleagues1Ramanathan K Antognini D Combes A et al.Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases.Lancet Respir Med. 2020; (published online March 20.)https://doi.org/10.1016/S2213-2600(20)30121-1Summary Full Text Full Text PDF PubMed Scopus (346) Google Scholar provide excellent recommendations for the use of extracorporeal membrane oxygenation (ECMO) for patients with respiratory failure from acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19). The authors describe pragmatic approaches to the challenges of delivering ECMO to patients with COVID-19, including training health-care personnel, resolving equipment and facilities issues, implementing systems for infection control and personal protection, providing overall support for health-care staff, and mitigating ethical issues. They also address some of the anticipated challenges with local and regional surges in COVID-19 ARDS cases; although there has been an increase in hospitals with the capacity to provide ECMO, the potential demand might exceed the available resources. Furthermore, some health-care systems offer advanced therapies such as ECMO but lack a coordinated local, regional, or national referral protocol. Given the practical constraints on substantially increasing the global availability of ECMO services in the next few months, it is important to emphasise the other evidence-based treatment options that can be provided for patients with severe ARDS from COVID-19 (figure).2Fielding-Singh V Matthay MA Calfee CS Beyond low tidal volume ventilation: treatment adjuncts for severe respiratory failure in acute respiratory distress syndrome.Crit Care Med. 2018; 46: 1820-1831Crossref PubMed Scopus (29) Google Scholar Before endotracheal intubation, it is important to consider a trial of high-flow nasal oxygen for patients with moderately severe hypoxaemia. This procedure might avoid the need for intubation and mechanical ventilation because it provides high concentrations of humidified oxygen, low levels of positive end-expiratory pressure, and can facilitate the elimination of carbon dioxide.4Frat J-P Thille AW Mercat A et al.High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.N Engl J Med. 2015; 372: 2185-2196Crossref PubMed Scopus (1370) Google Scholar WHO guidelines support the use of high-flow nasal oxygen in some patients, but they urge close monitoring for clinical deterioration that could result in the need for emergent intubations because such procedures might increase the risk of infection to health-care workers.5WHOInfection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance.https://apps.who.int/iris/rest/bitstreams/1266296/retrieveDate: 2020Date accessed: March 13, 2020Google Scholar For patients with COVID-19 who require endotracheal intubation, use of low tidal volume (6 mL/kg per predicted bodyweight) with a plateau airway pressure of less than 30 cm H2O, and increasing the respiratory rate to 35 breaths per min as needed, is the mainstay of lung-protective ventilation. If the hypoxaemia progresses to a PaO2:FiO2 ratio of less than 100–150 mm Hg, there are several therapeutic options. The level of positive end-expiratory pressure can be increased by 2–3 cm H2O every 15–30 min to improve oxygen saturation to 88–90%, with the goal of maintaining a plateau airway pressure of less than 30 cm H2O. Lower driving pressures (plateau airway pressure minus positive end-expiratory pressure) with a target of 13–15 cm H2O can also be used. If the patient is not responding to adjustment of the level of positive end-expiratory pressure, additional strategies might stabilise them. Recruitment manoeuvres probably have little value,6Sahetya SK Brower RG Lung recruitment and titrated PEEP in moderate to severe ARDS: is the door closing on the open lung?.JAMA. 2017; 318: 1327-1329Crossref PubMed Scopus (36) Google Scholar but moderate pressures of approximately 30 cm H2O for 20–30 s can be applied in the presence of a physician to monitor haemodynamics. If there is no improvement in oxygenation or driving pressure, or if the patient develops hypotension or barotrauma, the recruitment manoeuvres should be discontinued. If there is considerable dyssynchrony with positive pressure ventilation, accompanied by increased plateau airway pressures and refractory hypoxaemia, then deep sedation should be used followed by prompt institution of neuromuscular blockade with cisatracurium. Additionally, prone positioning should be instituted, unless there is a specific contraindication, and can be initiated along with the interventions already described. For persistent refractory hypoxaemia even with prone positioning, neuromuscular blockade, and efforts to optimise positive end-expiratory pressure therapy, there are additional options. Inhaled 5–20 ppm NO might improve oxygenation. Insertion of an oesophageal balloon to measure transpulmonary pressures to set an optimal positive end-expiratory pressure can be considered in patients with moderate-to-severe obesity, although a 2019 trial in patients with ARDS did not show the benefit of this procedure in most patients.7Beitler JR Sarge T Banner-Goodspeed VM et al.Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs an empirical high PEEP-FiO2 strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: a randomized clinical trial.JAMA. 2019; 321: 846-857PubMed Google Scholar Fluid management is important to consider as a measure to reduce pulmonary oedema.8Wiedemann HP Wheeler AP Bernard GR et al.Comparison of two fluid-management strategies in acute lung injury.N Engl J Med. 2006; 354: 2564-2575Crossref PubMed Scopus (2659) Google Scholar In the absence of shock, fluid conservative therapy is recommended to achieve a negative fluid balance of 0·5 to 1·0 L per day. In the presence of shock, fluid balance might be achieved with renal replacement therapy, especially if there is associated acute kidney injury and oliguria. Antibiotics should be considered since secondary bacterial infections have been reported in patients with COVID-19.9Huang C Wang Y Li Y et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Summary Full Text Full Text PDF PubMed Scopus (29072) Google Scholar Glucocorticoids should be avoided in view of the evidence that they can be harmful in cases of viral pneumonia and ARDS from influenza.10Ni Y-N Chen G Sun J Liang B-M Liang Z-A The effect of corticosteroids on mortality of patients with influenza pneumonia: a systematic review and meta-analysis.Critical Care. 2019; 23: 99Crossref PubMed Scopus (243) Google Scholar Rescue therapy with high-dose vitamin C can also be considered.11Fowler AA Truwit JD Hite RD et al.Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial.JAMA. 2019; 322: 1261-1270Crossref PubMed Scopus (465) Google Scholar Finally, ECMO should be considered using the inclusion and exclusion criteria of the EOLIA trial.3Combes A Hajage D Capellier G et al.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.N Engl J Med. 2018; 378: 1965-1975Crossref PubMed Scopus (1168) Google Scholar Since treatment of severe ARDS from COVID-19 is an ongoing challenge, it is important to learn from the patients who have been treated to gain an understanding of the disease's epidemiology, biological mechanisms, and the effects of new pharmacological interventions. Currently, there are some research groups working to coordinate and disseminate key information, including information on patients who have been treated with ECMO for COVID-19, although an accurate estimate of the number of such patients is not currently available. The Extracorporeal Life Support Organization is an international non-profit consortium that plans to maintain a registry of patients to facilitate an improved understanding of how ECMO is being used for patients with COVID-19. MAM reports grants from the National Institutes of Health—the National Heart, Lung and Blood Institute, the US Food and Drug Administration, the US Department of Defense, Bayer Pharmaceuticals, Genentech-Roche, and personal fees from Gen1e Life Sciences, outside of the submitted work. JMA has done been part of the electronic medical records committee of the Society of Critical Care Medicine, outside of the submitted work. JEG declares no competing interests. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseasesWHO interim guidelines recommend offering extracorporeal membrane oxygenation (ECMO) to eligible patients with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The number of patients with COVID-19 infection who might develop severe ARDS that is refractory to maximal medical management and require this level of support is currently unknown. Available evidence from similar patient populations suggests that carefully selected patients with severe ARDS who do not benefit from conventional treatment might be successfully supported with venovenous ECMO. Full-Text PDF

Treatment for severe acute respiratory distress syndrome from COVID-19