Ten things you need to know about intensive care unit management of mechanically ventilated patients with COVID-19

ABSTRACT

Introduction: The ongoing pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has posed important challenges for clinicians and health-care systems worldwide.

Areas covered: The aim of this manuscript is to provide brief guidance for intensive care unit management of mechanically ventilated patients with COVID-19 based on the literature and our direct experience with this population. PubMed, EBSCO, and the Cochrane Library were searched up until 15th of January 2021 for relevant literature.

Expert opinion: Initially, the respiratory management of COVID-19 relied on the general therapeutic principles for acute respiratory distress syndrome; however, recent findings have suggested that the pathophysiology of hypoxemia in patients with COVID-19 presents specific features and changes over time. Several therapies, including antiviral and anti-inflammatory agents, have been proposed recently. The optimal intensive care unit management of patients with COVID-19 remains unclear; therefore, ongoing and future clinical trials are warranted to clarify the optimal strategies to adopt in this cohort of patients.

KEYWORDS:

• Severe acute respiratory syndrome coronavirus-2
• mechanical ventilation
• anticoagulation
• antibiotic therapy
• corticosteroids

Article highlights

• The pathophysiology of respiratory failure in patients with COVID-19 presents peculiar features that require individualized treatment based on clinical laboratory and radiologic findings.

• Non-invasive respiratory support may help to reduce the need for intubation. However, prolonged non-invasive respiratory treatment can lead to patient self-inflicted lung injury and worse outcomes.

• Lung protective ventilation is warranted in critically ill patients with COVID-19. The role of PEEP needs further investigations and the optimal level of PEEP probably depends on the patient’s phenotype based on a CT scan and lung mechanics.

• Prone positioning, inhaled nitric oxide, respiratory dialysis, extracorporeal CO2 removal and extracorporeal membrane oxygenation can be considered as rescue therapies in selected patients with COVID-19, according to specific clinical and radiologic features.

• Bacterial co-infection at hospital admission and during the hospital stay can occur in patients with COVID-19. Strict clinical and laboratory monitoring and evaluation are necessary to decide whether and when to start antibiotic therapy.

• Thromboembolic complications are common in patients with COVID-19; in the absence of clear evidence regarding the best prophylactic and therapeutic treatment, patient management should be individualized based on the risk of bleeding and thrombosis and optimized case by case.

• Dexamethasone has shown beneficial effects on reducing the 28-day mortality rate and should be recommended in mechanically ventilated patients requiring supplementary oxygen.

• There is no evidence for routine use of antiviral and other adjuvant therapies in critically ill patients with COVID-19.

Acknowledgments

The authors would like to express their gratitude to Mrs. Moira Elizabeth Schottler (Rio de Janeiro) and Lorna O’Brien (authorserv.com) for their assistance in editing the manuscript.

Author contributions

CR, DB, LB, PP, and PRMR contributed to the literature review and the drafting of the manuscript. All authors read and approved the final manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplementary material

Supplemental data for this article can be accessed here.

Additional information

Funding

This paper was funded by the Brazilian Council for Scientific and Technological Development (COVID-19-CNPq) 401700/2020-8 and 403485/2020-7, the Rio de Janeiro State Research Foundation (COVID-19- FAPERJ) E-26/210.181/2020, Funding Authority for Studies and Projects (FINEP) 01200008.00, National Council for Scientific and Technological Development, and Brazilian Ministry of Science, Technology, and Information COVID-19 Network (RedeVírus MCTI).