COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted?

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances.

Healthcare systems worldwide are responding to Coronavirus Disease 2019 (COVID-19), an emerging infectious syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus. Patients with COVID-19 can progress from asymptomatic or mild illness to hypoxemic respiratory failure or multisystem organ failure, necessitating intubation and intensive care management. Healthcare providers, and particularly anesthesiologists, are at the frontline of this epidemic, and they need to be aware of the best available evidence to guide therapeutic management of patients with COVID-19 and to keep themselves safe while doing so. Here, the authors review COVID-19 pathogenesis, presentation, diagnosis, and potential therapeutics, with a focus on management of COVID-19-associated respiratory failure. The authors draw on literature from other viral epidemics, treatment of acute respiratory distress syndrome, and recent publications on COVID-19, as well as guidelines from major health organizations. This review provides a comprehensive summary of the evidence currently available to guide management of critically ill patients with COVID-19.

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COVID-19 Infection: Implications for Perioperative and Critical Care Physicians.

Introduction Pneumothorax and pneumomediastinum have both been noted to complicate cases of COVID-19 requiring hospital admission. We report the largest case series yet described of patients with both these pathologies that includes non-ventilated patients. Methods Cases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival. Results Seventy-one patients from 16 centres were included in the study, of whom 60 patients had pneumothoraces (six also with pneumomediastinum), whilst 11 patients had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication whilst intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1%±6.5%) or isolated pneumomediastinum (53.0%±18.7%; p=0.854). The incidence of pneumothorax was higher in males. The 28-day survival was not different between the sexes (males 62.5%±7.7% versus females 68.4%±10.7%; p=0.619). Patients above the age of 70 had a significantly lower 28-day survival than younger individuals (≥70 years 41.7%±13.5% survival versus Conclusion These cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage active treatment to be continued where clinically possible.

https://erj.ersjournals.com/content/erj/early/2020/09/03/13993003.02697-2020.full.pdf

COVID-19 and pneumothorax: a multicentre retrospective case series

Research significance: The extended version of this paper has been accepted by IEEE Internet of Things journal (DOI: 10.1109/JIOT.2020.2991456), please cite the journal version. During the epidemic prevention and control period, our study can be helpful in prognosis, diagnosis and screening for the patients infected with COVID-19 (the novel coronavirus) based on breathing characteristics. According to the latest clinical research, the respiratory pattern of COVID-19 is different from the respiratory patterns of flu and the common cold. One significant symptom that occurs in the COVID-19 is Tachypnea. People infected with COVID-19 have more rapid respiration. Our study can be utilized to distinguish various respiratory patterns and our device can be preliminarily put to practical use. Demo videos of this method working in situations of one subject and two subjects can be downloaded online. Research details: Accurate detection of the unexpected abnormal respiratory pattern of people in a remote and unobtrusive manner has great significance. In this work, we innovatively capitalize on depth camera and deep learning to achieve this goal. The challenges in this task are twofold: the amount of real-world data is not enough for training to get the deep model; and the intra-class variation of different types of respiratory patterns is large and the outer-class variation is small. In this paper, considering the characteristics of actual respiratory signals, a novel and efficient Respiratory Simulation Model (RSM) is first proposed to fill the gap between the large amount of training data and scarce real-world data. The proposed deep model and the modeling ideas have the great potential to be extended to large scale applications such as public places, sleep scenario, and office environment.

Abnormal respiratory patterns classifier may contribute to large-scale screening of people infected with COVID-19 in an accurate and unobtrusive manner

The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.

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Guidelines on the management of acute respiratory distress syndrome

Intravenous lipid emulsion (ILE) is increasingly used for the treatment of poisoning caused by lipid-soluble drugs. We report a case of reversal of cardiovascular collapse after the use of ILE in a patient with a mixed overdose, mainly of the calcium channel blocker felodipine. Conclusions that can be drawn from a single case are limited, but this report provides circumstantial evidence of benefit of ILE for felodipine poisoning. The use of ILE appears justified in cases refractory to conventional therapy.

https://journals.sagepub.com/doi/pdf/10.1177/175114371301400415

Nick T Tarmey

Papers

Guidelines on the management of acute respiratory distress syndrome

Intravenous Lipid Emulsion (ILE) Therapy for Severe Felodipine Toxicity