Management of COVID -19(ARDS)

COVID-19

Management of mild cases

· Mild cases are those with low-grade fever/cough/malaise/rhinorrhea/sore throat WITHOUT any shortness of breath
· Admission in COVID care centers
· Contact and droplet precautions, strict hand hygiene
· Symptomatic treatment
· Tab Hydroxychloroquine 400 mg BD for 1 day followed by 400 mg OD for 4 days in patients
with high-risk factors for a severe disease may be considered

Indications for hospital admission(moderate case)

The following criteria may be applied to consider for admission (Any ONE of the following):
1. Respiratory rate > 24/min
2. SpO2 < 94% on room air
3. Those at high risk for severe disease:
     a. Age > 60 years
     b. Cardiovascular disease including hypertension
     c. Diabetes mellitus/other immunocompromised states
     d. Chronic lung/liver/kidney disease
     e. Cerebrovascular disease
Consider Tab HCQ** (400 mg BD x 1 day f/b 400 mg OD x 4 days) **
Oxygen Support:
Target SpO2: 92-96% (88-92% in patients with COPD)The preferred device for oxygenation: preferably nonrebreathing face mask, venturi mask, HFNC
Monitor for Work of breathing
                                     Fatigue
                                     Hemodynamic instability
                                     Change in oxygen requirement

• Assessment of severity of hypoxemia/shunt

If the patient achieves a SpO2 >95% at 15L/min O2 the shunt fraction is mild. Failure to achieve this indicates a moderate-severe shunt fraction.
• If the target is not achieved/maintained with the above-mentioned devices,
cautious trials of CPAP via oro-nasal mask/NIV via helmet interface may be given.
• Try to achieve targets with the lowest possible PEEP.
• Use of CPAP/NIV requires intensive monitoring for any increase in work of breathing/large tidal volume breaths [to prevent self-inflicted lung injury (SILI)] and hemodynamic instability
Awake proning may be used as a rescue therapy
All patients should have daily 12-lead ECG Follow CRP, D-dimer, LDH, Trop I & Ferritin every 48-72 hourly; CBC w/diff, KFT/LFT & coagulation parameters daily Symptomatic and supportive treatment (antipyretics, antibiotics, etc. as per existing protocol)
Anticoagulation
A prophylactic dose of LMWH(e.g., enoxaparin1mg/kg per day SC)

Prone positioning in COVID-19 pneumonitis:

Awake proning prior to intubation:• May serve as an adjunct to using of non-invasive respiratory support and should only be used as a rescue therapy
• The benefit is usually short-lived and lies in the redistribution of perfusion
• Awake proning should only be considered if the patient:
o Is Able to communicate and co-operate with the procedure
o Is Able to rotate to front and adjust position independently
o Has no anticipated airway issue
If patients fulfill criteria for proning, ask the patient to switch positions every 30 min to 2 hours, while looking for improvement in oxygenation, as follows:
o Lying on the right side
o Sitting up (30-60 degrees) by adjusting the head of the bed
o Lying on left side
o Lying prone again

Fluid collection to bottom of lung

Pron position

For patients with a PaO₂/FiO₂ ratio of less than 150, the next maneuver is proning the patient or placing them in the proned position, to improve oxygenation to the posterior lungs. Proning the patient improves V/Q matching and allows the patient to have gas exchange along the posterior aspects of the lungs

How to intubate

· Intubation trolley should be prepared and kept ready in ICU
· Intubation checklist should be displayed inside ICU
· The most skilled member of the team should be identified at the beginning of each shift for performing intubation
· Ensure proper fit of N95 mask and face shield before attempting intubation
· Pre-oxygenate with 100% FiO2 for 3-5 minutes with closed-circuit (preferably)
· Try to avoid bag and mask ventilation (due to high risk of aerosol generation) but can be used if required by connecting an HME between mask and AMBU bag (or HME between
Use video laryngoscope and the endotracheal tube with stylet for intubation
· Rapid sequence intubation (RSI) to be done using available induction agents (preferably etomidate 0.3 mg/kg) and muscle relaxants (Succinylcholine 1.5mg/kg or Rocuronium 1.2mg/kg)
· Monitor for hemodynamic instability during induction
· Use visible chest rise, end-tidal CO2 and subsequently X-ray chest to confirm the correct position of the tube as auscultation may not be possible with PPE
· In unanticipated difficult airway when intubation is not successful in two attempts, use 2^nd generation laryngeal mask airway (i-Gel or Proseal LMA) as a rescue device for ventilation and call for expert help
· Insert nasogastric/orogastric tube at the same sitting to avoid repeat exposure
· Remove the outermost pair of gloves as early as possible to avoid contamination to other surfaces
· After intubation, appropriate cleaning/disinfection of equipment and environment should be done

COVID ICU admission(severe case):

1. Moderate/Severe ARDS
2. Multi-organ dysfunction
3. Shock
4. Transfer from ward to ICU if needs mechanical ventilation/closer monitoring

ARDS

The condition must be acute (< 7 days) uThe findings are not solely explained by cardiogenic pulmonary edema uThe chest X-ray must have bilateral opacities While on at least 5 cmH₂O of positive pressure ventilation, the ratio of PaO₂ to FiO₂ (expressed as a decimal, such as 0.7) must be < 300 uMild ARDS is a PaO₂/FiO₂ ratio of 200-300 Moderate ARDS is 100-199 Severe ARDS is < 100

lung compliance

This is the principle behind performing a recruitment maneuver and a “BestPEEP” trial to find a PEEP that optimizes compliance – preventing both atelectasis and overdistention

Minute ventilation

Tidal Volume	4-8 ml/kg PBW, starting with 6 ml/kg
Respiratory Rate	Higher, often > 20 breaths per minute
PEEP	≥ 8 cmH2O, avoiding overdistention
FiO2	Decrease as tolerated, SpO2 ≥ 92%

ventilator settings

Target:PaO2: 55-80 mmHg
PCO2: <45mmHg
pH >7.3
Pplat < 25-30 cmH2O
Antibiotics and antivirals as per clinician’s discretion (to cover community-acquired pneumonia including atypical pneumonia and Influenza)
Patients with high-risk factors should be transferred to the designated hospitals without delay.

Symptomatic treatment

· Maintain euvolemia
· Work of breathing:
o Excessive inspiratory efforts (requiring accessory muscles of respiration, large
volume tidal breaths, air hunger)
o Esophageal pressure monitoring (if available)
· Oxygen requirement
· Vital signs

Laboratory:

· Routine: CBC with differentials, LFT, KFT, coagulation profile, Urine R/M
· Predictive and prognostic markers: CRP, LDH, Ferritin, D-Dimer, Troponin I

Anticoagulation

• All hospitalized patients should be started on prophylactic LMWH (e.g., Enoxaparin 1mg/kg per day Subcutaneously) if not contraindicated, and no high-risk factors for bleeding are present
• Bleeding risk should be estimated with well-validated risk scores (e.g. HAS-BLED score of ≥3
signifies a higher bleeding risk)
• In a patient with a HAS-BLED score of 3, a risk-benefit analysis should be done considering the risk of thrombosis based on the level of D-dimer and SIC score ( ≥4 suggests a high risk of thrombosis)
• In patients who are admitted to ICU, consideration should be given to therapeutic dose LMWH
(e.g., enoxaparin 1mg/kg SC BD), if not at high risk of bleeding

Specific therapy:

· NO SPECIFIC ANTIVIRALS have been definitively proven to be effective as per currently available data.
· Drugs which have been tried in clinical trial settings include:
a) Hydroxychloroquine/Chloroquine b) Lopinavir/ritonavir c) Remdesivir d) Nitazoxanide e) Ivermectin
· Steroids may be considered in a defined subgroup of patients including:
o Patients with the critical disease diabetes and hypertension (admitted in the ICU)
Ø Given the potential for delayed viral clearance, the duration of steroid use should be limited to 3 to 5 days (with no tapering) in low to moderate doses (1-2mg/kg/day)
· Adjunctive therapy (may be considered):
Inj. Vit C 100mg/kg IV in 4 divided doses plus
Inj. Thiamine 200mg IV Q12 hourly

Supportive treatment in critically ill patients:

· Head end elevation (30 to 45 degrees)
· Oral hygiene with mouthwash
· Glycemic control to maintain blood sugar between 140 to 180 mg/dl
· Ulcer prophylaxis with proton pump inhibitors
· Foley’s catheter and Ryle’s tube placement
· Central venous catheter (CVC) insertion
· Pressure ulcer prevention by position change every 2 hourly

Ambu bag with filter

Care of ventilated patient:

· Fresh ventilator circuit to be used for every new patient
· Change circuit only when visibly soiled (not routinely)
· Use two HME filters- one at the patient end close to ETT and another at the ventilator end of the expiratory limb of the circuit. Do not use heated humidifiers
· HME-F to be changed only when visibly soiled
· Use closed inline suction system(avoid open suctioning)
· Use the same closed suction system to collect ET aspirate sample in a mucus trap chamber for RT-PCR
· Do not disconnect the circuit- push twist all connections
· In case disconnection is unavoidable (like patient transport) use deep sedation/muscle relaxation, put the ventilator on standby mode and clamp the ET tube just before disconnection
· Avoid nebulization (use MDI instead)
· Tracheostomy should preferably be delayed by the end of two weeks- possibility of decreased viral load
· Alternative ventilation strategy like APRV (Airway pressure release ventilation) and ECMO(extracorporeal membrane oxygenation) to be considered if indicated

Septic shock:

· Recognize septic shock in adults when the infection is suspected or confirmed AND vasopressors
are needed to maintain mean arterial pressure ≥ 65 mmHg AND lactate is ≥ 2 mmol/L in
absence of hypovolemia.
· Recognize septic shock in children with any hypotension or two or more of the following: altered mental state; bradycardia or tachycardia (Heart rate < 90/min or > 160/min in infants and < 70/min or > 150/min in children); prolonged capillary refill (> 2 sec) or feeble pulses; tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.
· Management should be as per surviving sepsis campaign guidelines
· Choice of antibiotics: as per indication (community-acquired vs hospital-acquired) and local
antibiogram

When to do dialysis:

· Urine output < 400 ml/24 hours
· Uremic encephalopathy
· Severe metabolic acidosis
· Uremic pericarditis
· Refractory hyperkalemia
· Fluid overload
Keep a low threshold for dialysis as fluid overload and acidosis are detrimental in ARDS.
Bedside dialysis to be preferred.

Pregnant patients:

· Testing to be prioritized
· Steroids may be given for fetal indications as per obstetrician’s advice
· Obstetrician to monitor fetal well-being daily
Breastfeeding patients:
Currently, there is no data suggestive of viral transmission via breast milk. However, due to close contact and risk of droplet transmission, breastfeeding should be avoided in COVID-19 confirmed mothers
Progressive worsening:
Consider:
-Tocilizumab (If IL-6 >5 ULN)
-Therapeutic Plasma Exchange

Discharge Criteria:

· Suspected case – if the laboratory results for COVID-19 are negative, discharge is to be decided as per discretion of the treating physician based on his provisional/confirmed
diagnosis
· Confirmed case – resolution of symptoms, radiological improvement with a documented virological clearance in 2 samples at least 24 hours apart
Download COVID-19 managenent PPT hear

-Dr Manish Khokhar MD