Care of Critically Ill Patients with COVID-19
Patricia Kritek, MD
COVID-19 patients with acute respiratory distress syndrome should be treated with the same interventions that other ARDS patients receive.
Reassuringly, we now know that a minority of patients with COVID-19 become critically ill. Although initial case series indicated high rates of intubation for patients admitted to the hospital (NEJM JW Gen Med May 15 2020 and N Engl J Med 2020; 382:2372) and shockingly high mortality in those with acute respiratory distress syndrome (ARDS; NEJM JW Infect Dis Jun 2020 and N Engl J Med 2020; 382:2012), subsequent reports reflect that mortality is similar in COVID-19 patients and those with other causes of ARDS (Am J Respir Crit Care Med 2020; 201:1560).
The mainstays of therapy for critically ill COVID-19 patients are those that we use for other patients with critical illness and ARDS. These include low tidal volume ventilation, conservative fluid management, and use of the prone position (NEJM JW Gen Med Apr 15 2020 and JAMA 2020; 323:1499). In the early months of the pandemic, substantial concern was expressed about scarcity of ventilators. In an effort to stave off intubation, experts recommended prone positioning for patients who were not yet intubated. Case series showed that this can be done safely, with improvement in oxygenation, but no evidence shows that patient-centered outcomes, such as need for mechanical ventilation and mortality, are affected (NEJM JW Gen Med Jul 1 2020 and JAMA 2020; 323:2336, 2338). Given the high incidence of venous thromboembolism in COVID-19 patients, multiple society guidelines recommend standard pharmacologic prophylaxis, preferably with low-molecular-weight heparin.
Another topic of debate is use of noninvasive ventilation and high-flow nasal cannula, both of which potentially help to avoid intubation but which also might increase risk of exposure to healthcare workers. A review of the literature on this topic in June 2020 reflected no definitive evidence to fully delineate potential risks and benefits of these interventions. Decisions most likely will remain institution-specific and reflect availability of mechanical ventilators and personal protective equipment (NEJM JW Gen Med Jul 1 2020 and Ann Intern Med 2020; 173:204).
Finally, extracorporeal membrane oxygenation (ECMO) has been used to support COVID-19 patients with severe ARDS. Although no randomized trials have been conducted, the most comprehensive registry data suggests that survival rates among patients treated with ECMO are similar to other patients with ARDS who are supported with ECMO. This remains a resource-intense intervention and decisions regarding ECMO will most likely be guided by staffing and other resource constraints (NEJM JW Gen Med Dec 1 2020 and Lancet 2020; 396:1071).
We have learned that once patients with COVID-19 have progressed to ARDS, they look very much like other patients with ARDS. The principles of care are essentially the same, albeit done on the backdrop of potential scarcity of resources and heightened concern of risk for transmission of infection.
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