Respiratory Support in COVID-19 Patients, with a Focus on Resource-Limited Settings

Arjen M Dondorp, Muhammad Hayat, Diptesh Aryal, Abi Beane, Marcus J Schultz, Arjen M Dondorp, Muhammad Hayat, Diptesh Aryal, Abi Beane, Marcus J Schultz

Abstract

The ongoing novel coronavirus disease (COVID-19) pandemic is threatening the global human population, including in countries with resource-limited health facilities. Severe bilateral pneumonia is the main feature of severe COVID-19, and adequate ventilatory support is crucial for patient survival. Although our knowledge of the disease is still rapidly increasing, this review summarizes current guidance on the best provision of ventilatory support, with a focus on resource-limited settings. Key messages include that supplemental oxygen is a first essential step for the treatment of severe COVID-19 patients with hypoxemia and should be a primary focus in resource-limited settings where capacity for invasive ventilation is limited. Oxygen delivery can be increased by using a non-rebreathing mask and prone positioning. The presence of only hypoxemia should in general not trigger intubation because hypoxemia is often remarkably well tolerated. Patients with fatigue and at risk for exhaustion, because of respiratory distress, will require invasive ventilation. In these patients, lung protective ventilation is essential. Severe pneumonia in COVID-19 differs in some important aspects from other causes of severe pneumonia or acute respiratory distress syndrome, and limiting the positive end-expiratory pressure level on the ventilator may be important. This ventilation strategy might reduce the currently very high case fatality rate of more than 50% in invasively ventilated COVID-19 patients.

References

    1. Alhazzani W, et al. 2020. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med [ePub ahead of print]. Available at: 10.1007/s00134-020-06022-5.
    1. Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS, 2020. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target. Intensive Care Med 46: 586–590.
    1. Lescure FX, et al. 2020. Clinical and virological data of the first cases of COVID-19 in Europe: a case series. Lancet Infect Dis [ePub ahead of print]. Available at: 10.1016/S1473-3099(20)30200-0.
    1. Huang C, et al. 2020. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395: 497–506.
    1. Zhou F, et al. 2020. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 395: 1054–1062.
    1. Tian S, Hu W, Niu L, Liu H, Xu H, Xiao SY, 2020. Pulmonary pathology of early-phase 2019 novel coronavirus (COVID-19) pneumonia in two patients with lung cancer. J Thorac Oncol [ePub ahead of print]. Available at: 10.1016/j.jtho.2020.02.010.
    1. Zhou M, Zhang X, Qu J, 2020. Coronavirus disease 2019 (COVID-19): a clinical update. Front Med [ePub ahead of print]. Available at: 10.1007/s11684-020-0767-8.
    1. Tang N, Li D, Wang X, Sun Z, 2020. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 18: 844–847.
    1. Verity R, et al. 2020. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis [ePub ahead of print]. Available at: 10.1016/S1473-3099(20)30243-7.
    1. Yang X, et al. 2020. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med [ePub ahead of print]. Available at: 10.1016/S2213-2600(20)30079-5.
    1. van den Boom W, Hoy M, Sankaran J, Liu M, Chahed H, Feng M, See KC, 2020. The search for optimal oxygen saturation targets in critically Ill patients: observational data from large ICU databases. Chest 157: 566–573.
    1. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A, 2020. Coronavirus disease 2019 (COVID-19): a systematic review of Imaging findings in 919 patients. AJR Am J Roentgenol [ePub ahead of print]. Available at: 10.2214/AJR.20.23034.
    1. Zhou S, Wang Y, Zhu T, Xia L, 2020. CT features of coronavirus disease 2019 (COVID-19) pneumonia in 62 patients in Wuhan, China. AJR Am J Roentgenol [ePub ahead of print]. Available at: 10.2214/AJR.20.22975.
    1. Phua J, et al. Asian Critical Care Clinical Trials G , 2020. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med [ePub ahead of print]. Available at: 10.1016/S2213-2600(20)30161-2.
    1. Wang L, Li X, Chen H, Yan S, Li D, Li Y, Gong Z, 2020. Coronavirus disease 19 Infection does not result in acute kidney Injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [ePub ahead of print]. Available at: 10.1159/000507471.
    1. Meara JG, et al. 2015. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386: 569–624.
    1. Duke T, Peel D, Wandi F, Subhi R, Sa’avu M, Matai S, 2010. Oxygen supplies for hospitals in Papua New Guinea: a comparison of the feasibility and cost-effectiveness of methods for different settings. P N G Med J 53: 126–138.
    1. Bradley BD, Light JD, Ebonyi AO, N'Jai PC, Ideh RC, Ebruke BE, Nyassi E, Peel D, Howie SR, 2016. Implementation and 8-year follow-up of an uninterrupted oxygen supply system in a hospital in the Gambia. Int J Tuberc Lung Dis 20: 1130–1134.
    1. Bakare AA, et al. 2020. Providing oxygen to children and newborns: a multi-faceted technical and clinical assessment of oxygen access and oxygen use in secondary-level hospitals in southwest Nigeria. Int Health 12: 60–68.
    1. Dat VQ, Long NT, Giang KB, Diep PB, Giang TH, Diaz JV, 2017. Healthcare infrastructure capacity to respond to severe acute respiratory infection (SARI) and sepsis in Vietnam: a low-middle income country. J Crit Care 42: 109–115.
    1. Chen W, Janz DR, Shaver CM, Bernard GR, Bastarache JA, Ware LB, 2015. Clinical characteristics and outcomes are similar in ARDS diagnosed by oxygen saturation/Fio2 ratio compared with pao2/Fio2 ratio. Chest 148: 1477–1483.
    1. Riviello ED, Kiviri W, Twagirumugabe T, Mueller A, Banner-Goodspeed VM, Officer L, Novack V, Mutumwinka M, Talmor DS, Fowler RA, 2016. Hospital incidence and outcomes of the acute respiratory distress syndrome using the Kigali modification of the Berlin definition. Am J Respir Crit Care Med 193: 52–59.
    1. Vercesi V, et al. 2018. External confirmation and exploration of the Kigali modification for diagnosing moderate or severe ARDS. Intensive Care Med 44: 523–524.
    1. Arabi YM, Arifi AA, Balkhy HH, Najm H, Aldawood AS, Ghabashi A, Hawa H, Alothman A, Khaldi A, Al Raiy B, 2014. Clinical course and outcomes of critically ill patients with middle east respiratory syndrome coronavirus infection. Ann Intern Med 160: 389–397.
    1. Inglis R, Ayebale E, Schultz MJ, 2019. Optimizing respiratory management in resource-limited settings. Curr Opin Crit Care 25: 45–53.
    1. Ayebare RR, Flick R, Okware S, Bodo B, Lamorde M, 2020. Adoption of COVID-19 triage strategies for low-income settings. Lancet Respir Med 8: e22.
    1. Slutsky AS, Ranieri VM, 2013. Ventilator-induced lung injury. N Engl J Med 369: 2126–2136.
    1. Walkey AJ, et al. 2017. Higher PEEP versus lower PEEP strategies for patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 14: S297–S303.
    1. Constantin JM, et al. 2019. Personalised mechanical ventilation tailored to lung morphology versus low positive end-expiratory pressure for patients with acute respiratory distress syndrome in France (the LIVE study): a multicentre, single-blind, randomised controlled trial. Lancet Respir Med 7: 870–880.
    1. Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A, 2000. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342: 1301–1308.
    1. Fan E, et al. American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine , 2017. An Official American Thoracic Society/European Society of Intensive care Medicine/society of critical care medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 195: 1253–1263.
    1. Rhodes A, et al. 2017. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 43: 304–377.
    1. Villar J, et al. Spanish Initiative for Epidemiology, Stratification and Therapies for ARDS (SIESTA) Investigators Network , 2017. A quantile analysis of plateau and driving pressures: effects on mortality in patients with acute respiratory distress syndrome receiving lung-protective ventilation. Crit Care Med 45: 843–850.
    1. Guerin C, et al. 2013. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368: 2159–2168.
    1. Munshi L, et al. 2017. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 14: S280–S288.
    1. Scholten EL, Beitler JR, Prisk GK, Malhotra A, 2017. Treatment of ARDS with prone positioning. Chest 151: 215–224.
    1. Albert RK, Keniston A, Baboi L, Ayzac L, Guerin C, Proseva I, 2014. Prone position-induced improvement in gas exchange does not predict improved survival in the acute respiratory distress syndrome. Am J Respir Crit Care Med 189: 494–496.
    1. van Meenen DM, Roozeman JP, Serpa Neto A, Pelosi P, Gama de Abreu M, Horn J, Cremer OL, Paulus F, Schultz MJ, Consortium M, 2019. Associations between changes in oxygenation, dead space and driving pressure induced by the first prone position session and mortality in patients with acute respiratory distress syndrome. J Thorac Dis 11: 5004–5013.
    1. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M, 2020. Characteristics and outcomes of 21 critically Ill patients with COVID-19 in Washington state. JAMA [ePub ahead of print]. Available at: 10.1001/jama.2020.4326.
    1. Bhatraju PK, et al. 2020. Covid-19 in critically Ill patients in the seattle region - case series. N Engl J Med [ePub ahead of print]. Available at: 10.1056/NEJMoa2004500.

Source: PubMed

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