COVID-19 patients: when and whom to ventilate?

Tusharindra Lal; Mrinal Sircar

doi:10.4266/acc.2020.00451

Articles

Page Path: HOME > Acute Crit Care > Volume 35(3); 2020 > Article

Letter to the Editor Pulmonary COVID-19 patients: when and whom to ventilate?: Tusharindra Lal¹, Mrinal Sircar²; Acute and Critical Care 2020;35(3):218-219.
DOI: https://doi.org/10.4266/acc.2020.00451
Published online: August 19, 2020

¹Sri Ramachandra Institute of Higher Education and Research, Chennai, India

²Department of Pulmonology and Critical Care, Fortis Hospital, Noida, India

Corresponding author Tusharindra Lal Sri Ramachandra Institute of Higher Education and Research, Chennai-600116, Tamil Nadu, India Tel: +91-9560273362 E-mail: tusharindralal@gmail.com

• Received: June 28, 2020 • Accepted: July 17, 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

4,100 Views
118 Download
1 Web of Science
1 Crossref
1 Scopus

prev next

Full Article

Download PDF

NOTES
References

Dear editor:

The coronavirus disease-19 (COVID-19) pandemic has severely strained intensive care unit (ICU) resources worldwide. It is estimated that a country like India with a population of 1.3 billion, has one doctor for every 1,457 individuals, 1.7 nurses per 1,000 people, approximately 1.9 million hospital beds, 95 thousand ICU beds, and 48 thousand ventilators. As the cases of severe acute respiratory syndrome (SARS) increase rapidly, finding ICU beds, ventilators, intensivists, and critical care nurses remains a big challenge. The need for mechanical ventilation in COVID-19 patients, however, remains a subject of debate. A Chinese study reported that invasive ventilation was required in only 2.3% of 1,099 COVID-19 positive patients [1]. In contrast, noninvasive ventilation (NIV), including bilevel positive airway pressure and continuous positive airway pressure, is being advocated for early/mild disease [1]. Patients needing mechanical ventilation were sicker and had a higher mortality rate, as compared to those receiving NIV. Additionally, the PaO₂/FiO₂ ratio was worse among nonsurvivors [2]. A meta-analysis that included 1,084 patients from eight selected studies showed that high-flow nasal cannula (HFNC) treatment could reduce the rate of endotracheal intubation and ICU mortality [3]. A more recent review concluded that HFNC and NIV should be reserved for patients with mild acute respiratory distress syndrome until further data are available [4]. Although aerosolization risk exists for both HFNC (up to 62 cm around the face) and NIV (within 92 cm distance), the former has been recommended by surviving sepsis guidelines [5,6]. NIV must be delivered with a well-fitted full-face non-vented mask, delivered in negative pressure (or single) rooms, and by adding a viral filter between the mask and the expiratory leak or tubing. Besides face masks, NIV may also be provided by nasal pillows (aerosolization risk up to 33 cm distance) and helmet masks (aerosolization risk up to zero to 27 cm distance) [5].

Potentially, HFNC and NIV have the advantage of being provided even outside the ICU and can be managed by trained paramedical staff which conserves ICU resources for more severe patients [7]. Further, recent research has shown an emerging role for awake prone HFNC and NIV [8]. Awake prone positioning improves the mismatch between ventilation-perfusion and opens the atelectatic lungs by promoting adequate sputum drainage. Many patients will immediately improve their oxygenation while others show signs of exhaustion or excessive respiratory effort. High tidal volumes (breathing spontaneously or on HFNC/NIV), may expose diseased lungs to swings of trans-pulmonary pressures and may lead to patient self-inflicted lung injury. Any undue delay in switching to invasive ventilation may worsen outcomes [9]. A recent study has shown that maximal level of interleukin-6 (IL-6), followed by C-reactive protein (CRP) level, was highly predictive of the need for mechanical ventilation suggesting the possibility of using IL-6 or CRP level to guide escalation of treatment in patients with COVID-19-related hyperinflammatory syndrome [10].

With medical facilities severely stretched out, especially in resource-limited regions like India and other developing nations with large population clusters, selective use of HFNC or NIV may reduce the need for ventilated ICU beds while achieving desired clinical results. The decision to switch from HFNC/NIV to invasive ventilation could be a tricky one with several factors and co-morbidities to be taken into account. However, in the absence of randomized controlled trials (RCTs) and lack of clear guidelines, the clinical judgment of physicians and the availability of necessary resources in their respective hospitals will largely determine the ventilation techniques employed. Large RCTs or well-designed observational studies are needed to define stratification of COVID-19 patients for the best choice of initial respiratory support keeping in mind the resources available and the judicious and timely use of invasive ventilation.

NOTES

CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Conceptualization: all authors. Data curation, Formal analysis: TL. Methodology, Project administration & Visualization: all authors. Writing–original draft: TL. Writing–review & editing: MS.

References

1. Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology 2020;132:1317-32.Article PubMed
2. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. 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 2020;8:475-81.Article PubMed PMC
3. Ni YN, Luo J, Yu H, Liu D, Liang BM, Liang ZA. The effect of high-flow nasal cannula in reducing the mortality and the rate of endotracheal intubation when used before mechanical ventilation compared with conventional oxygen therapy and noninvasive positive pressure ventilation: a systematic review and meta-analysis. Am J Emerg Med 2018;36:226-33.Article PubMed
4. Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020;8:506-17.Article PubMed PMC
5. Ferioli M, Cisternino C, Leo V, Pisani L, Palange P, Nava S. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev 2020;29:200068. Article PubMed PMC
6. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med 2020;46:854-87.Article PubMed PMC PDF
7. Simonelli C, Paneroni M, Fokom AG, Saleri M, Speltoni I, Favero I, et al. How the COVID-19 infection tsunami revolutionized the work of respiratory physiotherapists: an experience from Northern Italy. Monaldi Arch Chest Dis 2020;90.Article PMC
8. Xu Q, Wang T, Qin X, Jie Y, Zha L, Lu W. Early awake prone position combined with high-flow nasal oxygen therapy in severe COVID-19: a case series. Crit Care 2020;24:250. Article PubMed PMC PDF
9. Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med 2017;195:438-42.Article PubMed
10. Herold T, Jurinovic V, Arnreich C, Lipworth BJ, Hellmuth JC, von Bergwelt-Baildon M, et al. Elevated levels of IL-6 and CRP predict the need for mechanical ventilation in COVID-19. J Allergy Clin Immunol 2020;146:128-36.e4.Article PubMed PMC

Figure & Data

References

Citations

Citations to this article as recorded by

Comparison of characteristics and ventilatory course between coronavirus disease 2019 and Middle East respiratory syndrome patients with acute respiratory distress syndrome
Imran Khalid, Romaysaa M Yamani, Maryam Imran, Muhammad Ali Akhtar, Manahil Imran, Rumaan Gul, Tabindeh Jabeen Khalid, Ghassan Y Wali
Acute and Critical Care.2021; 36(3): 223. CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.