Coronavirus Disease 2019 (COVID-19) - Critical Care and Airway Management Issues - UpToDate

04/09/2020 Coronavirus disease 2019 (COVID-19): Critical care and airway management issues - UpToDate
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Coronavirus disease 2019 (COVID-19): Critical care and airway

management issues
Author: George L Anesi, MD, MSCE, MBE
Section Editor: Scott Manaker, MD, PhD
Deputy Editors: Geraldine Finlay, MD, Allyson Bloom, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2020. | This topic last updated: Aug 31, 2020.
INTRODUCTION
A novel coronavirus was identified in late 2019 as the cause of a cluster of pneumonia cases in Wuhan,
China. It has since rapidly spread resulting in a pandemic. The World Health Organization designated the
disease term COVID-19 (ie, Coronavirus Disease 2019) [1]. The virus that causes COVID-19 is designated
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The major morbidity and mortality from
COVID-19 is largely due to acute viral pneumonitis that evolves to acute respiratory distress syndrome
(ARDS).
This topic will discuss the epidemiology, clinical features, and management of patients who become critically
ill due to COVID-19. Other aspects of COVID-19, and other coronavirus-related diseases (severe acute
respiratory syndrome [SARS] and Middle East respiratory syndrome [MERS]), are discussed separately.
(See "Coronavirus disease 2019 (COVID-19): Questions and answers" and "Coronavirus disease 2019
(COVID-19): Clinical features" and "Coronavirus disease 2019 (COVID-19): Management in hospitalized
adults" and "Coronaviruses" and "Severe acute respiratory syndrome (SARS)" and "Middle East respiratory
syndrome coronavirus: Virology, pathogenesis, and epidemiology".)
GUIDELINES AND HOSPITAL POLICIES
The advice in this topic is based upon data derived from the management of patients with acute respiratory
distress syndrome, emerging retrospective data in patients with COVID-19, expert opinion, and anecdotal
observations of clinicians treating patients with COVID-19 in China, Italy, and the United States, where the
large outbreaks have occurred. Guidelines have been issued by several societies and organizations including
the Society of Critical Care Medicine, the Chinese Thoracic Society, the Australian and New Zealand
Intensive Care Society (ANZICS), the World Health Organization and by the United States Centers for
Disease Control and Prevention and National Institutes of Health [2-9]. (See "Society guideline links:
Coronavirus disease 2019 (COVID-19) – International public health and government guidelines".)
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Learning from regions that have dealt with the overwhelming burden of COVID-19 to date, it is essential that
all hospitals and health systems develop task forces to manage patients admitted with this disorder. This
involves, but is not limited to, designating COVID-19-specific intensive care units (ICUs) and ICU teams,
creating back up and expanded staffing schedules, utilizing detailed protocols for infection prevention and
medical management, accessing research trials for patients with COVID-19, ensuring adequate personal
protection equipment (PPE) supplies and training, forecasting demand, and prioritizing diagnostic lab testing.
EPIDEMIOLOGY
Reports suggest that among those infected with severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2), up to 20 percent develop severe disease requiring hospitalization [10-18]. Although rates vary,
among those who are hospitalized, up to one-quarter need intensive care unit (ICU) admission, representing
approximately 5 to 8 percent of the total infected population. Differences in the rates of ICU admission may
relate to cultural differences in practice and admission criteria for ICU as well as differences in predisposing
factors such as age and comorbidities and testing availability in the populations served.
● China – In the Chinese cohorts, rates of ICU admission or severe illness ranged from 7 to 26 percent
[11,12,17,19].
● Italy - Consistent with the range reported in China, preliminary reports from Italy suggest that the
proportion of ICU admissions were between 5 and 12 percent of the total positive SARS-CoV-2 cases,
and 16 percent of all hospitalized patients [20,21].
● United States of America – Among 5700 patients hospitalized with COVID-19 in New York, 1151 (20
percent) required mechanical ventilation [18]. In an early study of 21 critically ill patients in Washington
State, USA, 81 percent of patients with COVID-19 pneumonia were admitted to the ICU and 71 percent
were mechanically ventilated [22]. However, this high rate likely reflects the older age of the population
which largely came from a nursing home in the region. A larger analysis of 2449 patients reported
hospitalization rates of 20 to 31 percent and ICU admission rates of 4.9 to 11.5 percent [23]. In an
analysis of a second surge in Houston, Texas, a smaller proportion of patients were admitted to the ICU
compared with the first surge (20 versus 38 percent) [24]. Lower rates of ICU admission may have
reflected a younger cohort of patients who had fewer comorbidities or growing comfort with caring for
COVID-19 patients outside of the ICU.
While three-quarters of critically ill patients were male in the Chinese cohorts, data from other areas are
mixed with some reports suggesting an equal proportion of men and women [21,22] and other suggesting a
male predominance [25,26].
CLINICAL FEATURES IN CRITICALLY ILL PATIENTS
Clinical features and complications — General clinical features of COVID-19 patients and risk factors for
progression are discussed separately (see "Coronavirus disease 2019 (COVID-19): Clinical features",
section on 'Risk factors for severe illness'). Discussion here is limited to clinical features in those who are
critically ill.
● Rate of progression – Retrospective studies of critically ill patients have suggested that among patients
who develop critical illness, including acute respiratory distress syndrome (ARDS), onset of dyspnea is
relatively late (median 6.5 days after symptom onset), but progression to ARDS can be swift thereafter
(median 2.5 days after onset of dyspnea) [11,12,22,27-29].
● Clinical features – Among those who are critically ill, profound acute hypoxemic respiratory failure from
ARDS is the dominant finding [10-12,22,25,26,28,30-38]. Hypercapnia is rare. Fevers tend to wax and
wane during ICU admission. The need for mechanical ventilation in those who are critically ill is high
ranging from 30 to 100 percent [11,22,25,26,30,33,38].
● Length of stay – Early clinical reports suggest that length of intensive care unit (ICU) stay appears to be
long with many patients remaining intubated for one to two weeks or longer [26]. Reports from experts in
the field suggest that many patients fail early attempts at weaning (eg, within the first week), although
this does not appear to predict their eventual ability to wean and extubate. Only a small proportion of
patients require tracheostomy. (See 'Extubation and weaning' below and 'Tracheostomy' below.)
● Complications – Common complications of COVID-19-related ARDS include acute kidney injury (AKI),
elevated liver enzymes, and cardiac injury including cardiomyopathy, pericarditis, pericardial effusion,
arrhythmia, and sudden cardiac death. As an example, in a single-center retrospective cohort from
China of 52 critically ill patients with COVID-19, complications included AKI (29 percent; half of whom
needed renal replacement therapy), liver dysfunction (29 percent), and cardiac injury (23 percent) [11].
• Cardiac injury appears to be a late complication, developing after the respiratory illness improves. A
high rate of cardiomyopathy was noted in a United States cohort (33 percent), and may relate to the
older age in that population [22]. In another United States cohort in New York City, cardiac
complications among mechanically ventilated patients included atrial arrhythmias (18 percent),
myocardial infarction (8 percent), and heart failure (2 percent) [32]. One case series reported five
patients who developed acute cor pulmonale, most of which occurred in association with
hemodynamic instability or cardiac arrest [39]. All cases were thought to be most likely due to
pulmonary embolism (PE), although a definitive diagnosis of PE was confirmed in only one case.
Cardiac complications of COVID-19 are discussed in detail elsewhere. (See "Coronavirus disease
2019 (COVID-19): Myocardial injury" and "Coronavirus disease 2019 (COVID-19): Arrhythmias and
conduction system disease" and "Coronavirus disease 2019 (COVID-19): Myocardial infarction and
other coronary artery disease issues".)
• Sepsis, shock, and multi-organ failure do occur but appear to be less common when compared with
non-COVID-19-related ARDS. The need for vasoactive agents is variable, although a significant
proportion need vasopressor support for hypotension (often due to sedation medications or cardiac
dysfunction). In the cohort study from Wuhan, China, 35 percent of 52 patients received vasoactive
agents [11]. In contrast, in the case series from New York City, 95 percent of the 130 patients who
received mechanical ventilation required vasopressor support; the reasons for this were not
specified [32].
• As above, acute kidney injury is common among critically ill patients with COVID-19, and many
require renal replacement therapy. This is discussed in detail elsewhere. (See "Coronavirus disease
2019 (COVID-19): Issues related to kidney disease and hypertension", section on 'Acute kidney
injury'.)
• Data on the risk of secondary bacterial pneumonia are limited, but it does not appear to be a major
feature of COVID-19. In a cohort of intubated patients from China, hospital-acquired pneumonia, in
many cases with resistant pathogens, was reported in 12 percent [11]. This finding may be related
to the high use of glucocorticoids for ARDS management in China. Further data are needed to
elucidate the rate of superinfection in other countries.
• Lung compliance is high compared with other etiologies of ARDS and the rate of barotrauma
appears to be low with only 2 percent developing pneumothorax, compared with 25 percent of those
with severe acute respiratory syndrome coronavirus (SARS-CoV) [11,40]. There are limited data
describing the lung pathology in patients with COVID-19. Case reports from post mortem cases and
patients undergoing biopsy for another reason suggest a wide variation from mononuclear
inflammation to diffuse alveolar damage, classic of ARDS [41,42]. (See "Acute respiratory distress
syndrome: Epidemiology, pathophysiology, pathology, and etiology in adults", section on 'Pathologic
stages'.)
• Neurologic complications in critically ill patients are common, especially delirium or encephalopathy
which manifests with prominent agitation and confusion along with corticospinal tract signs
(hyperreflexia). Consistent with this, intensivists have observed that sedation requirements are high
in this population, particularly immediately after intubation. In one series of 58 patients with COVID-
19-related ARDS, delirium/encephalopathy was present in approximately two-thirds of patients [43].
In addition, three of 13 patients who had brain MRI had an acute ischemic stroke; eight MRI studies
demonstrated leptomeningeal enhancement. Cerebrospinal fluid (CSF) in seven patients was
acellular and only one had elevated CSF protein; PCR assays of CSF were negative for the virus. It
is unclear whether the neurologic complications noted in this and other reports are due to critical
illness, medication effects, or represent more direct effects of cytokines or the SARS-CoV-2 virus
[43-45]. Encephalitis, while reported, is rare [46]. Similarly, Guillain-Barré-barre syndrome following
SARS-CoV-2 virus infection has also been described in a small case series [47]. The neurologic
complications of COVID-19 are described in detail separately. (See "Coronavirus disease 2019
(COVID-19): Neurologic complications and management of neurologic conditions".)
• A hypercoagulable state is common in this population with some patients developing abnormal
coagulation profiles and others developing thrombosis despite prophylactic and sometimes
therapeutic anticoagulation. These features are discussed separately. (See "Coronavirus disease
2019 (COVID-19): Hypercoagulability".)
● Laboratory – Laboratory findings in critically ill patients (eg leukopenia, lymphopenia, leukocytosis,
elevated D-dimer, lactate dehydrogenase, and ferritin, normal or low procalcitonin) are initially modest
and similar to those with milder illness, although the procalcitonin level may be more elevated and
lymphopenia more profound in critically ill patients [10,12,31]. (See "Procalcitonin use in lower
respiratory tract infections" and "Cytokine release syndrome (CRS)" and "Coronavirus disease 2019
(COVID-19): Management in hospitalized adults", section on 'IL-6 pathway inhibitors' and "Coronavirus
disease 2019 (COVID-19): Clinical features", section on 'Laboratory findings'.)
Some patients with severe COVID-19 have laboratory evidence of an exuberant inflammatory response,
similar to cytokine release syndrome (CRS), with persistent fevers, elevated inflammatory markers (eg,
D-dimer, ferritin, interleukin-6), and elevated proinflammatory cytokines; these laboratory abnormalities
have been associated with poor prognosis [48]. Rare cases of Hemophagocytic lymphohistiocytosis
(HLH) have also been described [49]. Clinical trials of anti-IL-6 agents for the treatment of COVID-19 are
in progress. Further details regarding CRS are provided separately. (See "Procalcitonin use in lower
respiratory tract infections" and "Cytokine release syndrome (CRS)" and "Coronavirus disease 2019
(COVID-19): Management in hospitalized adults", section on 'IL-6 pathway inhibitors' and "Coronavirus
disease 2019 (COVID-19): Clinical features", section on 'Laboratory findings'.)
The presence of antiphospholipid antibodies has also been described; however, they are mostly of the
IgA subclass, and the clinical significance is unclear [50]. Abnormal coagulation parameters which are
commonly seen in COVID-19 patients (eg, elevated D-dimer, prolonged prothrombin time) are also
discussed separately. (See "Coronavirus disease 2019 (COVID-19): Hypercoagulability" and "Diagnosis
of antiphospholipid syndrome".)
● Imaging – Typical imaging findings do not appear to be different in mild or severe cases of COVID-19
(eg, ground-glass opacification with or without consolidative abnormalities, consistent with viral
pneumonia, minimal or no pleural effusions) [11,51-57]. Findings are often initially peripheral and may
include a “reverse halo sign”. While imaging with chest computed tomography (CT) was commonly
performed in Chinese cohorts, we prefer to avoid its use, unless necessary; if chest CT is used as a
diagnostic tool, its use must be balanced with the risk to other patients and healthcare workers during
the process of patient transport and time spent in the CT room. Characteristic findings on bedside lung
ultrasound include thickening of the pleural line and B lines supporting alveolar consolidation. Pleural
effusions are unusual [58]. Guidance from The Fleischner Society on the role of chest imaging has been
published [56]. In addition, guidance from The American Society of Echocardiography on the use of
bedside ultrasound has been published and focuses on using this modality to determine whether
additional imaging is warranted (eg, echocardiography) and the necessary precautions for infection
control with device use [59]. (See "Coronavirus disease 2019 (COVID-19): Clinical features", section on
'Imaging findings'.)
Pathology — There are a paucity of data describing lung pathology of COVID-19 pneumonia in critically ill
patients. Most autopsy reports describe hyaline membrane changes and microvessel thrombosis suggestive
of early ARDS (ie, exudative and proliferative phases of diffuse alveolar damage [DAD]) [42,60-69]. Other
findings include bacterial pneumonia (isolated or superimposed on DAD) and viral pneumonitis [61,65]. Less
common findings include acute fibrinous organizing pneumonia (AFOP; in the late stages) [70], amyloid
deposition (heart and lung), and rarely alveolar hemorrhage and vasculitis [65]. (See "Interpretation of lung
biopsy results in interstitial lung disease", section on 'Diffuse alveolar damage'.)
Evidence of pulmonary thrombosis and thromboembolism has been reported in autopsy series [61,65,66,71].
(See "Coronavirus disease 2019 (COVID-19): Hypercoagulability", section on 'Clinical features'.)
Distant organ involvement has also been seen with the demonstration of virus in organs other than the lung
and, in some cases, acute tubular necrosis and a generalized thrombotic microangiopathy in the kidney
[61,65]. (See "Coronavirus disease 2019 (COVID-19): Issues related to kidney disease and hypertension".)
Risk factors for progression — Age appears to be the major risk factor that predicts progression to ARDS
[14,22,23,29,30]. Comorbidities, high fever (≥39°C), history of smoking, blood type, obesity, and select
laboratory features also predict progression and death from COVID-19. Importantly, adults of any age may
develop severe disease and experience adverse outcomes, especially those with comorbidities. Further
details regarding the risk of disease progression are provided separately. (See "Coronavirus disease 2019
(COVID-19): Clinical features", section on 'Risk factors for severe illness'.)
RESPIRATORY CARE OF THE NONINTUBATED PATIENT
Specific aspects of respiratory care relevant to deteriorating patients with COVID-19 before admission to the
intensive care unit (ICU) are discussed here (table 1). These include oxygenation with low flow and high-flow
systems, noninvasive ventilation and the administration of nebulized medications. For hospitalized patients
who develop progressive symptoms, early admission to the ICU is prudent when feasible.
Self-proning — Some experts, including us, are encouraging that the hospitalized patient with COVID-19
spend as much time as is feasible and safe in the prone position while receiving oxygen or noninvasive
modalities of support such a high flow oxygen delivered via nasal cannulae (HFNC) or noninvasive ventilation
(NIV). The rationale for this approach is based upon limited direct evidence and anecdotal observations in
the field as well as indirect evidence of its efficacy in ventilated patients with acute respiratory distress
syndrome (ARDS). (See 'Prone ventilation' below and 'Monitoring on noninvasive modalities' below.)
Emerging evidence suggests that proning is feasible and results in improved oxygenation in some patients
with COVID-19, regardless of whether they are receiving supplemental oxygen only, HFNC, or NIV [71-80]. It
remains unclear whether pronation averts intubation, accelerates recovery, or reduces mortality. Future data
are warranted to identify the optimal indications for and duration of pronation, and assessment of response.
● In a retrospective study, 12 out of 15 COVID-19 patients treated with NIV and pronation (median total of
two cycles, three hours) experienced an improvement in the peripheral oxygen saturation while the
remainder either stabilized or deteriorated [77].
● In another prospective study of 24 COVID-19 patients with hypoxemic respiratory failure, a third of whom
were on oxygen flow of four liters or more (including HFNC), 15 patients (63 percent) could tolerate
prone positioning for more than three hours [78]. Among those who tolerated prone positioning, six (40
percent) experienced improvements in oxygenation during prone positioning but in three of those
improvement was not sustained upon resupination.
● In another prospective cohort of 56 patients, prone positioning was maintained for at least three hours in
the majority (89 percent) [79]. For the whole group, oxygenation improved from a partial arterial pressure
of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio of 181 mmHg (supine) to 286 mmHg (prone).
Improved oxygenation was maintained in half of those studied (labeled as “responders”). Approximately
one-quarter of patients were eventually intubated regardless of whether they were a responder or non-
responder.
Oxygenation targets — The World Health Organization (WHO) suggests titrating oxygen to a target
peripheral oxygen saturation (SpO2) of ≥94 percent during initial resuscitation and ≥90 percent for
maintenance oxygenation. For most critically ill patients, we prefer the lowest possible fraction of inspired
oxygen (FiO2) necessary to meet oxygenation goals, ideally targeting a SpO2 between 90 and 96 percent, if
feasible. Hyperoxia should be avoided. If a higher SpO2 is achieved during initial resuscitation and
stabilization, such as during intubation, supplemental oxygen should be weaned as soon as is safe and
possible to avoid prolonged hyperoxia. Individualization of the goal is important such that some patients may
warrant a lower target (eg, patients with a concomitant acute hypercapnic respiratory failure from chronic
obstructive pulmonary disease [COPD]) and others may warrant a higher target (eg, pregnancy). Data that
support this target range are provided separately. (See "Overview of initiating invasive mechanical ventilation
in adults in the intensive care unit", section on 'Fraction of inspired oxygen'.)
Low flow oxygen — For patients with COVID-19, supplemental oxygenation with a low flow system via
nasal cannula or oxygen pendant (picture 1) is appropriate (ie, up to 6 L/min). Although the degree of micro-
organism aerosolization at low flow rates is unknown, it is reasonable to surmise that it is minimal.
Higher flows of oxygen may be administered using a simple face mask, venturi face mask, or nonrebreather
mask (eg, up to 10 to 20 L/minute), but as flow increases, the risk of dispersion also increases, augmenting
the contamination of the surrounding environment and staff.
Many experts have patients who wear nasal cannula also wear a droplet mask, especially during transport or
when staff are in the room. Data to support this practice are largely non-peer-reviewed or derived from
simulation experiments but make practical sense as a maneuver to reduce the infectious risk associated with
potential aerosolization [81-83]. Additional information on the provision of low flow oxygen is provided
separately. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)
Patients with higher oxygen requirements — As patients progress, higher amounts of oxygen are needed.
Options at this point in non-COVID-19 patients are high-flow oxygen via nasal cannulae (HFNC) or the
initiation of noninvasive ventilation (NIV). Both modalities have been used variably. In retrospective cohorts,
rates for HFNC use ranged from 14 to 63 percent while 11 to 56 percent were treated with NIV [11,26,30,33].
While, there are no prospective data describing whether these modalities were successful at avoiding
intubation, one retrospective study described the highest level of respiratory support in hospitalized COVID-
19 patients was noninvasive modalities (HFNC and NIV) in 5.4 percent of patients and invasive ventilation in
30 percent [33]. Notably, a sudden increase in oxygen requirement should raise the suspicion for pulmonary
embolism, which is a common complication of COVID-19. (See "Coronavirus disease 2019 (COVID-19):
Hypercoagulability".)
Deciding on a modality (noninvasive modalities or invasive ventilation) — In patients with COVID-19

who have acute hypoxemic respiratory failure and higher oxygen needs than low flow oxygen can provide,
we suggest that noninvasive modalities may be used rather than proceeding directly to intubation. We
believe that the decision to initiate noninvasive modalities, HFNC or NIV, should be made by balancing the
risks and benefits to the patient, the risk of exposure to healthcare workers, and best use of resources [84];
this approach should be reassessed as new data become available. We encourage the development of
hospital protocols and a multidisciplinary approach, which includes respiratory therapy staff, to facilitate this
decision.
Early during the pandemic, some experts advocated for the avoidance of both modalities (ie, proceeding to
early intubation if escalating beyond 6 L/min with continued hypoxemia or increased work of breathing). This
was predicated on an increased risk of aerosolization and high likelihood that patients who need these
modalities will ultimately, rapidly deteriorate and require mechanical ventilation (eg, within one to three days).
However, in our opinion, using this as an absolute rule may result in an excess of unnecessary intubations
and place an undue load on ventilator demand as the disease surges. In addition, this is particularly
problematic for patients under investigation (eg, COVID-19 testing pending), patients who have chronic
nocturnal NIV requirements, patients with chronic respiratory failure who have high baseline oxygen
requirements, and patients with do-not-intubate status but who might benefit otherwise from NIV or HFNC.
Ultimately, these recommendations may change with time depending on the case load of COVID-19 patients
in a given location.
Oxygen via high flow nasal cannula versus noninvasive ventilation — Among the noninvasive
modalities, we prefer HFNC. Our preference for HFNC is based upon limited and inconsistent data, which, on
balance, favor HFNC compared with NIV in patients with non-COVID-19- and COVID-19-related acute
hypoxemic respiratory failure; data in non-COVID-19 patients are provided separately. (See "Heated and
humidified high-flow nasal oxygen in adults: Practical considerations and potential applications", section on
'Medical patients with severe hypoxemic respiratory failure'.)
However, NIV may be appropriate in patients with indications that have proven efficacy; these include
patients with acute hypercapnic respiratory failure from an acute exacerbation of chronic obstructive
pulmonary disease (AECOPD), patients with acute cardiogenic pulmonary edema, and patients with sleep
disordered breathing (eg, obstructive sleep apnea or obesity hypoventilation). These data are provided
separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and
contraindications", section on 'Patients likely to benefit'.)
Overall, the data on the use of HFNC and NIV in patients with COVID-19 are limited [84,85]. A systematic
review from July 2020 identified one trial evaluating HFNC in patients with COVID-19, which suggested that it
reduced the need for mechanical ventilation [85]. Another systematic review that included evidence from
patients with SARS and MERS as well as COVID-19 reported that NIV might reduce the rate of intubation
and mortality, based on low quality evidence [84]. However, NIV may also increase the risk for transmission
of SARS-CoV-2 to health care workers. Furthermore, the data on NIV are mixed, as some studies suggest a
high failure rate of NIV in patients with MERS [86] and other causes of ARDS. (see "Noninvasive ventilation
in adults with acute respiratory failure: Benefits and contraindications", section on 'Hypoxemic
nonhypercapnic respiratory failure NOT due to ACPE')
Monitoring on noninvasive modalities — If HFNC or NIV is administered, vigilant monitoring of patients

is warranted for progression with frequent clinical and arterial blood gas evaluation every one to two hours to
ensure efficacy and safe ventilation (eg, frequent coughing may not be “safe”). We advocate a low threshold
to intubate such patients, particularly if they show any signs of rapid progression. (See 'Timing' below.)
Data to support self-proning during HFNC and NIV and technical details regarding application of HFNC
and NIV are provided separately. (See 'Self-proning' above and "Heated and humidified high-flow nasal
oxygen in adults: Practical considerations and potential applications" and "Noninvasive ventilation in
adults with acute respiratory failure: Practical aspects of initiation" and "Noninvasive ventilation in adults
with acute respiratory failure: Benefits and contraindications".)
Precautions for noninvasive modalities — HFNC and NIV are considered aerosol generating
procedures. Thus, when HFNC or NIV is used, airborne in addition to standard precautions should be
undertaken (ie, airborne infection isolation room [also known as a negative pressure room], full personal
protective equipment). (See "Coronavirus disease 2019 (COVID-19): Infection control in health care and
home settings", section on 'Patients with suspected or confirmed COVID-19'.)
● HFNC – We advocate additionally placing a surgical or N95 mask on the patient during HFNC when
healthcare workers are in the room, but the value of this practice is unknown [3]. Additional precautions
for HFNC that have potential to reduce risk include starting at and using the lowest effective flow rate
(eg, 20 L/minute and 0.4 FiO2). Inhaled medications or gases (eg, epoprostenol, nitric oxide
bronchodilators) should be avoided during HFNC.
● NIV – If NIV is initiated, a full-face mask rather than a nasal or oronasal mask is preferred to minimize
particle dispersion. The mask should preferably have a good seal and not have an anti-asphyxiation
valve or port. Use of a helmet has been proposed for delivering NIV to patients with COVID-19 [87].
However, experience is limited with this delivery method, especially in the United States. If NIV is used,
dual limb circuitry with a filter on the expiratory limb on a critical care ventilator may decrease dispersion
compared with single limb circuitry on portable devices, although data to support this are lacking. We
also suggest starting with continuous positive airway pressure (CPAP) using the lowest effective
pressures (eg, 5 to 10 cm H2O).
There are few data regarding aerosolization during HFNC and NIV [82,88-90]. In a normal lung simulation
study, dispersion of air during exhalation increased with increasing HFNC flow from 65 mm (at 10 L/minute)
to 172 mm (at 60 L/minute) mostly along the sagittal plane (ie, above the nostrils) [88]. Similar distances
were found when CPAP was delivered via nasal pillows (up to 332 mm with CPAP 20 cm H2O). However,
there was no significant leakage noted when CPAP was administered via an oronasal mask with good seal
(picture 2 and picture 3). Air leak increased when connections on any device were loose. Dispersion seemed
to be reduced when the simulator simulated injured lung. In vitro and clinical studies have also shown that a
surgical mask placed on the patient may decrease the dispersion distance [91].
Novel devices targeting limitation of aerosol spread from patients receiving HFNC or NIV have been
proposed but are not yet commercially available nor has their impact on clinical outcomes been tested [92].
Nebulized medications (spontaneously breathing patients) — Nebulizers are associated with

aerosolization and potentially increase the risk of SARS-CoV-2 transmission. In patients with suspected or
documented COVID-19, nebulized bronchodilator therapy should be reserved for acute bronchospasm (eg, in
the setting of asthma or chronic obstructive pulmonary disease [COPD] exacerbation). Otherwise, nebulized
therapy should generally be avoided, in particular for indications without a clear evidence-base; however
some uses (eg, hypertonic saline for cystic fibrosis) may need to be individualized. Metered dose inhalers
(MDIs) with spacer devices should be used instead of nebulizers for management of chronic conditions (eg,
asthma or COPD controller therapy). Patients can use their own MDIs if the hospital does not have them on
formulary. (See "Delivery of inhaled medication in adults", section on 'Implications of covid-19 pandemic'.)
If nebulized therapy is used, patients should be in an airborne infection isolation room, and healthcare
workers should use contact and airborne precautions with appropriate personal protection equipment (PPE);
this includes a N95 mask with goggles and face shield or equivalent (eg, powered air-purifying respirator
[PAPR] mask]) as well as gloves and gown. All non-essential personnel should leave the room during
nebulization. Some experts also suggest not re-entering the room for two to three hours following nebulizer
administration. (See "Coronavirus disease 2019 (COVID-19): Infection control in health care and home
settings".)
Other — Potential for transmission of SARS-CoV-2 should inform the use of other interventions in patients
with documented or suspected COVID-19:
● It is prudent to minimize the following:
• Positive airway devices for chronic nocturnal ventilation support

• Chest physical therapy or oscillatory devices
• Oral or airway suctioning
● Sputum induction should be avoided
● Bronchoscopy should be avoided in spontaneously breathing patients and limited to therapeutic

indications (eg, life-threatening hemoptysis, central airway stenosis)
If any of these therapies are performed, similar PPE to that described for nebulizer therapy should be used.
(See 'Nebulized medications (spontaneously breathing patients)' above and "Flexible bronchoscopy in adults:
Overview".)
THE DECISION TO INTUBATE
Timing — Timing of intubation in this population is challenging. Most patients with acute respiratory distress
syndrome (ARDS) due to COVID-19 will warrant intubation and mechanical ventilation. Delaying intubation
until the patient acutely decompensates is potentially harmful to the patient and healthcare workers and is not
advised. For patients with escalating oxygen requirements, we monitor clinical and gas exchange parameters
every one to two hours and have a low threshold to intubate patients with the following:
● Rapid progression over hours

● Lack of improvement on >50 L/minute of high flow oxygen and a fraction of inspired oxygen (FiO2) >0.6
● Evolving hypercapnia, increasing work of breathing, increasing tidal volume, worsening mental status
● Hemodynamic instability or multiorgan failure
Most experts with experience managing COVID-19 patients suggest “early” intubation. However, the
definition of what constitutes “early” is unclear. Use of noninvasive means are traditionally used to avoid
intubation. However, their use is subject to controversy in patients with COVID-19 (see 'Patients with higher
oxygen requirements' above). Clinicians should communicate closely and regularly about the potential for
intubation in patients that are being followed and treated noninvasively so that the transition for intubation
can be smooth and rapid once it has been identified that the patient needs intubation.
Precautions — Intubation is the highest risk procedure for droplet dispersion in patients with COVID-19 [93-
95]. While quantification of the risk has been poorly documented, one prospective study of self-reported
COVID-19 infection in healthcare workers reported a cumulative incidence of 3.6, 6.1, and 8.5 percent at 7,
14, and 21 days post a tracheal intubation procedure [95].
The following discussion is suitable for patients outside the operating room (eg, intensive care unit [ICU] and
emergency department) (table 2).
● We are proponents of the development of intubation kits and intubation checklists for performing rapid
sequence intubation (RSI) in this population (figure 1). In the hypoxic, agitated patient who cannot
cooperate with preoxygenation efforts, delayed sequence intubation (DSI) may be performed to ensure
adequate preoxygenation (table 2).
● Attention should be paid to donning full contact and airborne personal protective equipment (PPE)
(figure 2 and figure 3) [93]. Appropriate PPE includes a fit-tested disposable N95 respirator mask
(picture 4), with eye protection or a powered air-purifying respirator (PAPR), also known as an isolation
suit (picture 5 and picture 6). Also included are gown, caps and beard covers, protective footwear, neck
covering, and gloves (using the double glove technique). (See "Coronavirus disease 2019 (COVID-19):
Infection control in health care and home settings".)
● Intubation should be performed in an airborne infection isolation room, if possible.
● Intubation should be performed by the most qualified individual (eg, anesthesiologist) since delayed
intubation with multiple attempts may prolong dispersion and place the patient at risk of a respiratory
arrest.
● Anecdotally, most experts suggest optimizing preoxygenation with nonaerosol-generating means (eg,
avoidance of high flow oxygen delivered via nasal cannula) and intubation using video laryngoscopy. In
patients previously on high flow oxygen, some experts switch to 100 percent nonrebreather masks for
preoxygenation.
● When manual bag mask ventilation (BMV) is needed, switching the mask to a supraglottic device for
manual bagging is appropriate. When feasible, BMV should be minimized before and after intubation,
and a bacterial/viral high efficiency hydrophobic filter should be placed between the facemask and
breathing circuit or resuscitation bag. Having a pre-prepared bag-mask with filter attached in every room
with a COVID-19 patient is prudent. Using a two-person technique for an adequate face mask seal is
also suggested.
● Clamping the endotracheal tube (ETT) for connections and disconnections is appropriate (eg,
capnography testing following intubation), only if the patient is NOT spontaneously breathing.
● The ventilator and ventilator circuitry should be ready in advance with preplanned settings already
entered so that as soon as the ETT is placed and confirmed with capnography, it can be connected
directly to the ETT without additional manual bagging. In addition, if feasible, in-line suction devices and
in-line adapters for bronchoscopy should be prepared and attached to the ventilator tubing in advance in
order to avoid unnecessary disconnection for their placement at a later point in time. The expiratory limb
on the ventilator should have a HEPA filter to decrease contamination of the ventilator and environment
and protect staff when changing limb circuitry.
● To minimize exposure, bundling intubation with other procedures is appropriate as is bundling the chest
radiograph for ETT and central venous catheter placement.
● Doffing should follow strict procedure and some experts also advocate for the use of viricidal wipes for
areas of exposed skin during intubation (eg, neck) (figure 3).
Novel passive barrier protection intubation devices have been proposed. However, concern about the
potential for viral spread and impeded performance has led the FDA to revoke the umbrella emergency use
authorization for passive protective barrier enclosures without negative pressure [96]. As an example, an
“aerosol intubation box” was designed so that it could be placed over a patient’s head allowing intubation to
be performed through two circular ports on the cephalad side of the box. Initial simulation experiments
suggested significant reduction in aerosol deposition to the individual performing intubation and the
surrounding environment compared to when no device was used [97]. However, subsequent simulation
studies suggested significant delays in intubation and breaches in PPE with the device use [98,99].
Detailed guidance regarding intubation in the operating room, optimal personal protective equipment, and
procedural details regarding intubation itself are discussed separately. (See "Coronavirus disease 2019
(COVID-19): Anesthetic concerns, including airway management and infection control" and "Safety in the
operating room", section on 'COVID-19' and "Direct laryngoscopy and endotracheal intubation in adults" and
"Rapid sequence intubation for adults outside the operating room" and "The decision to intubate" and
"Induction agents for rapid sequence intubation in adults outside the operating room" and "Neuromuscular
blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room".)
VENTILATOR MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME
Most patients with COVID-19 who are mechanically ventilated appear to have acute respiratory distress
syndrome (ARDS). Accurate data on duration of ventilation are limited but suggest prolonged mechanical
ventilation for two weeks or more (table 1). All of the steps discussed below should proceed as resources
allow.
Whether different phases of COVID-19 pneumonitis require different ventilatory strategies is unclear. One
school of thought is that in the early phase of COVID-19, severe hypoxemia is associated with high
compliance and low alveolar recruitability (atypical ARDS), while in the later phase, severe hypoxemia is
associated with low lung compliance and high recruitability (classic ARDS) [100,101]. However, this
hypothesis, remains unproven and optimal ventilatory strategies based upon it are unclear. Until further data
are available, we prefer a strategy that promotes lung protection as outlined in the sections below.
Low tidal volume ventilation (LTVV) — As for all patients with ARDS, patients with COVID-19 pneumonia
who develop ARDS requiring mechanical ventilation should receive LTVV targeting ≤6 mL/kg predicted body
weight (PBW; range 4 to 8 mL/kg PBW (table 3 and table 4)). We typically use a volume-limited assist control
mode, beginning with a tidal volume of 6 mL/kg PBW, which targets a plateau pressure (Pplat) ≤30 cm H2O,
and applies positive end-expiratory pressure (PEEP) according to the strategy outlined in the table (table 5).
This approach is based upon several randomized trials and meta-analyses that have reported improved
mortality from LTVV in patients with ARDS. The experience among Chinese, Italian, and United States
cohorts is that this approach is also beneficial in this population. Modifications to or deviations from this
mechanical ventilation strategy may be required in the setting of severe hypercapnia or ventilator
dyssynchrony (figure 4). (See "Ventilator management strategies for adults with acute respiratory distress
syndrome", section on 'Patients who are not improving or deteriorating'.)
Anecdotal reports suggest that the COVID-19 ARDS phenotype is one of severe hypoxemia that is
responsive to high PEEP with relatively high lung compliance such that Pplat ≤30 cm H2O is not difficult to
achieve. As a consequence, we and other clinicians have a low threshold to start with higher than usual
levels of PEEP (eg, 10 to 15 cm H2O).
Expanded details on LTVV and other ventilator strategies in ARDS are provided separately. (See "Ventilator
management strategies for adults with acute respiratory distress syndrome".)
We believe that oxygenation goals in critically ill patients with COVID-19 should be similar to those in
nonventilated patients (ie, peripheral oxygen saturation between 90 and 96 percent (see 'Oxygenation
targets' above)). However, in patents with COVID-19, some experts use a higher peripheral oxygen
saturation (SpO2) goal [7]. The rationale for this approach is that it may reduce the frequency of ventilator
adjustments that require staff entry into the room, thereby reducing the risk to healthcare staff, although data
are lacking to support it.
Reflecting the practice of LTVV, one retrospective Italian cohort reported that the median level of PEEP was
14 cm H2O (interquartile range [IQR] 12 to 16 cm H2O) [26]. Ninety percent of patients required an FiO2 >0.5,
and the median PaO2/FiO2 ratio was 160 (IQR, 114 to 220).
Failure of low tidal volume ventilation — For patients with COVID-19 that fail to achieve adequate
oxygenation with LTVV, we agree with other experts in the field who have chosen prone ventilation as the
preferred next step. For its application, we use similar criteria to those in non-COVD-19 patients (ie, partial
arterial pressure of oxygen/fraction of inspired oxygen [PaO2:FiO2] ratio <150 mmHg, a FiO2 ≥0.6, and PEEP
≥5 cm H2O; excessively high airway pressures; or recalcitrant hypoxemia), although some experts use a
higher PaO2:FiO2 ratio, given the good response seen in this population.
Prone ventilation — Our preference for using prone ventilation is based on its known efficacy in patients
with ARDS as well as limited and anecdotal observations of intensivists in the field who have noted that
unlike patients who had severe acute respiratory syndrome coronavirus (SARS-CoV), patients with COVID-
19-related ARDS respond well to this maneuver [102]. Those who are experienced in ventilating patients with
COVID-19-related ARDS also promote ventilating patients prone for as long as is feasible without
prematurely returning the patient to the supine position (ie, 12 to 16 hours prone per day) and to perform the
maneuver at change of shift when sufficient staff are available. The utmost care should be taken to avoid
ventilator disconnections during proning and the number of personnel should be limited to that required for
turning. This video which describes the prone procedure is freely available. Additional details regarding the
efficacy, contraindications (table 6) and application (table 7) of prone ventilation are provided separately. (See
"Prone ventilation for adult patients with acute respiratory distress syndrome" and "Ventilator management
strategies for adults with acute respiratory distress syndrome", section on 'Ventilator strategies to maximize
alveolar recruitment'.)
The good response to prone positioning may be due to preserved lung compliance in this population
compared with patients who develop ARDS from other etiologies. Lung compliance is the change in lung
volume for a given pressure. It can be measured using the following equations: lung compliance (C) =
change in lung volume (V) / change in transpulmonary pressure (alveolar pressure [Palv] – pleural pressure
[Ppl]); static lung compliance = tidal volume / Pplat – PEEP. The normal lung compliance is approximately
200 mL/cm H2O and in general compliance >50 mL/cm H2O has been noted by clinicians who have
experienced ventilating patients with COVID-19.
Optimal timing and criteria for discontinuing prone ventilation is unclear and should be performed on an
individualized basis. It is not unreasonable to use criteria similar to that in studies that have shown benefit in
non-COVID-related ARDS (eg PaO2:FiO2 ≥150 mmHg, FiO2 ≤0.6, PEEP ≤10 cm H2O) maintained for at least
four hours after the end of the last prone session) [103].
Additional measures — Additional options for patients in whom prone ventilation fails include the
following:
● Recruitment and high PEEP – Recruitment maneuvers and high PEEP strategies (table 8) may be
performed to address severe hypoxemia [8]; data supporting their use in non COVID-19-related ARDS is
described separately. (See "Ventilator management strategies for adults with acute respiratory distress
syndrome", section on 'Ventilator strategies to maximize alveolar recruitment'.)
● Pulmonary vasodilators – Pulmonary vasodilators may improve ventilation-perfusion mismatch in

patients with severe hypoxemia (eg, PaO2:FiO2 <100) and may be especially helpful in those with
decompensated or acute pulmonary arterial hypertension [8]. However, pulmonary vasodilators do not
improve mortality in all-cause ARDS and should not be used instead of evidence-based therapies such
as prone positioning. Namely, in a patient whose PaO2:FiO2 ratio meets proning criteria, but numerically
improves with the initiation of pulmonary vasodilators, prone positioning should not be withheld. (See
"Acute respiratory distress syndrome: Supportive care and oxygenation in adults", section on
'Investigational agents'.)
The two most commonly used agents are inhaled nitric oxide gas (iNO) and aerosolized epoprostenol,
which are administered by continuous inhalation. After initiating iNO or epoprostenol, the response is
typically noted within a few hours (eg, 10 percent reduction in FiO2 requirement). The choice of agent is
typically institution dependent based on local expertise and cost. While some centers use a single agent,
other centers use an initial trial of iNO (eg, 30 parts per million [PPM] for one hour) to determine
responsiveness; responders are continued on iNO or transitioned to inhaled epoprostenol. iNO may be
preferred since it is associated with a less frequent need to change filters with resultant reduction in the
risk to the respiratory healthcare provider.
Inhaled vasodilators should only be administered through a closed system and require skilled personnel
for their use. Potential risks and challenges with COVID-19 patients include aerosolization and clogging
of bacterial/viral filters used in ventilator circuits, particularly with epoprostenol. Further details regarding
their use are described separately. (See "Acute respiratory distress syndrome: Supportive care and
oxygenation in adults", section on 'Nitric oxide' and "Acute respiratory distress syndrome: Supportive
care and oxygenation in adults", section on 'Prostacyclin' and "Inhaled nitric oxide in adults: Biology and
indications for use", section on 'Acute hypoxemic respiratory failure'.)
● Neuromuscular blocking agents (NMBAs) – NMBAs may be reserved for patients with refractory
hypoxemia or ventilator dyssynchrony. We do not favor their routine use in any patient with ARDS since
data on outcomes are conflicting. (See "Acute respiratory distress syndrome: Supportive care and
oxygenation in adults", section on 'Paralysis (neuromuscular blockade)' and "Neuromuscular blocking
agents in critically ill patients: Use, agent selection, administration, and adverse effects".)
● Extracorporeal membrane oxygenation (ECMO) – While the World Health Organization suggests
ECMO as a rescue strategy, we only use it in those who fail prone ventilation and the other evidence-
based medical strategies listed above. In addition, ECMO is not universally available. As many hospitals
choose to cohort patients in COVID-19-only intensive care units (ICUs), there may also be the challenge
of delivering ECMO in ICUs that do not routinely care for ECMO patients; this would require the
recruitment of additional specialized nursing and perfusionist staff. ECMO can also reduce the
lymphocyte count and raise the interleukin-6 level, thereby interfering with the interpretation of these
laboratory results [104]. (See "Extracorporeal membrane oxygenation (ECMO) in adults" and
"Coronavirus disease 2019 (COVID-19): Extracorporeal membrane oxygenation (ECMO)".)
Use of rescue strategies has varied among centers. Among 66 mechanically-ventilated patients with COVID-
19 in Boston, Massachusetts, 31 (47 percent) underwent prone positioning, 18 (27 percent) were treated with
inhaled vasodilator, and 3 (5 percent) received ECMO; overall mortality was 27 percent at a minimum follow-
up of 30 days [105]. In a single-center retrospective cohort of 52 critically ill patients with COVID-19 in
Wuhan, China, approximately 12 percent received prone ventilation and 12 percent received ECMO [11]. In
contrast, in the original cohort of 138 hospitalized patients with COVID-19, of the 17 patients who required
invasive mechanical ventilation, 24 percent were treated with ECMO. Similarly, in an Italian cohort, only 1
percent of critically ill patients received ECMO [26].
Additional ventilator precautions — We recommend tight seals for all ventilator circuitry and equipment.
For patients who have a tracheostomy, similar recommendations apply. Although the efficacy is unproven,
some experts suggest placing the ventilator and intravenous (IV) line monitors outside the room, when
feasible (eg, through a wall port). This allows frequent ventilator adjustments while simultaneously
decreasing the risk of exposure to staff; although the efficacy of such maneuvers is unproven.
It is prudent to avoid unnecessary disconnection with the endotracheal tube (ETT) in ventilated patients with
COVID-19 in order to avoid derecruitment and unnecessary exposure of virus to the environment. For
example, in-line suction devices and in-line adapters for bronchoscopy are preferred, if resources allow. If
disconnection is necessary (eg, during transfer when portable ventilators are used or manual bagging), the
ETT should be temporarily clamped during disconnection and unclamped after reconnection. This is
considered an aerosolizing procedure in which case an airborne infection isolation room is preferable but is
not always feasible.
Other infection precautions include use of dual limb ventilator circuitry with filters placed at the exhalation
outlets as well as heat moisture exchange (HME) systems rather than heated humification of single limb
circuits. HME should be placed between the exhalation port and the ETT (figure 5 and figure 6). (See "The
ventilator circuit".)
It is particularly important to adhere to the standard practice of maintaining the ETT cuff pressure between 25
and 30 cm H2O so that a tight seal exists between the cuff and the tracheal wall. (See "Complications of the
endotracheal tube following initial placement: Prevention and management in adult intensive care unit
patients", section on 'Maintain optimal cuff pressure'.)
All ventilators should have appropriate filters in place and agreed upon filter change schedule (eg, every six
hours). The ventilator should be wiped down after every filter change.
Although an airborne isolation room is ideal, if not feasible, patients can be ventilated in a non-isolation room
but need to be transported to an airborne isolation room when aerosol generating procedures take place (eg,
extubation, bronchoscopy). Having a protocol in place for transport is prudent.
INTERVENTIONS
Ventilated patients require frequent evaluation and develop complications that require intervention. Details
relevant to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection are included in this
section and mostly relate to infectious precautions.
In a biodistribution study of 1070 specimens obtained from 205 patients with COVID-19 pneumonia,
bronchoalveolar lavage fluid specimens showed the highest positive rates (93 percent), followed by sputum
(72 percent), nasal swabs (63 percent), fibrobronchoscope brush biopsy (46 percent), pharyngeal swabs (32
percent), feces (29 percent), and blood (1 percent). No urine specimens tested positive [106]. These data
demonstrate that SARS-CoV-2 may be detected in several specimens, although the reported rates in this
study may have been determined by the severity of illness of the individual tested.
In a systematic review of 10 retrospective cohort studies which evaluated transmission of severe acute
respiratory syndrome coronavirus (SARS-CoV) to healthcare workers, endotracheal intubation had the
highest risk (odds ratio [OR] 6.6, 95% CI 2.3-18.9), followed by noninvasive ventilation (OR 3.1, 95% CI 1.4-
6.8), tracheostomy (OR 4.2, 95% CI 1.5-11.5), and bag-mask ventilation [107]. Other procedures were
associated with a lower or insignificant risk of transmission but it is not known whether they can be applied to
SARS-CoV-2. For example, duration of close contact during aerosolizing procedures and precautions used
were not described.
Collection of respiratory specimens in the intubated patient — Some intubated patients require upper or
lower respiratory tract sampling for diagnostic purposes (eg, diagnosis of COVID-19 or ventilator-associated
pneumonia [VAP]). Technically, nasopharyngeal and oropharyngeal swabs do not have to be taken under
airborne precautions. Nonetheless, we prefer to obtain naso- and oropharyngeal swabs and tracheal
aspirates under airborne precautions in the intensive care unit (ICU). For the diagnosis of COVID-19, the
Society of Critical Care Medicine suggest that in patients with negative upper respiratory tract samples in
whom suspicion remains, endotracheal aspirates can be obtained. Nonbronchoscopic alveolar lavage (“mini-
BAL”) may also be performed as an alternative to bronchoscopy, although experience in this procedure is not
universal among ICUs. If mini-BAL is performed for the diagnosis of COVID-19, use of smaller aliquots of
lavage fluid is prudent (eg, three 10 mL aliquots to obtain 2 to 3 mL of fluid). (See "Clinical presentation and
diagnostic evaluation of ventilator-associated pneumonia", section on 'Invasive respiratory sampling'.)
Bronchoscopy — We agree with the American Association for Bronchology and Interventional Pulmonology
(AABIP) that bronchoscopy should have a limited role for the diagnosis of COVID-19 and should only be
performed for this indication when upper respiratory samples are negative (ie, nasopharyngeal and
oropharyngeal swabs, tracheal aspirates, or non-bronchoscopic bronchoalveolar lavage) and the suspicion
remains high. Bronchoscopy may also be performed when another diagnosis is being considered and a
bronchoscopic sample would change management (eg, suspected Pneumocystis jirovecii in an
immunosuppressed patient) or when therapeutic bronchoscopy is indicated (eg, life-threatening hemoptysis
or airway stenosis).
Bronchoscopy is an aerosol-generating procedure and should only be performed when necessary and likely
to change management. Bronchoscopy through an established airway (eg, endotracheal tube [ETT]) likely
carries less risk than bronchoscopy in a spontaneously breathing patient. In patients with COVID-19,
bronchoscopy should be performed in an airborne infection isolation room. Airborne precautions and
personal protective equipment (PPE) should be donned before entering the room. Using PPE similar to that
described for intubation is appropriate. (See 'The decision to intubate' above and "Coronavirus disease 2019
(COVID-19): Infection control in health care and home settings".)
Using ETTs with inline adapters for bronchoscopy is ideal to prevent disconnection from the ventilator and
aerosolization. If bronchoscopy is needed for the diagnosis of COVID-19 pneumonia, then we suggest small
aliquots of 10 mL to obtain 2 to 3 mL of lavage fluid placed in a sterile leak-proof container. Clamping suction
tubing or turning off suction after the sample has been obtained before disconnecting the sample from the
device is also prudent. Specimens should be in a double zip-locked sealed plastic bag, handled with the
usual precautions, and labelled clearly as “COVID-19.”
We prefer the use of disposable bronchoscopes, although these are not universally available. For
nondisposable equipment, we recommend cleaning the suction channels with standard cleaning solutions
typically used for highly infectious material. We also suggest covering or sealing any vessel containing the
bronchoscope during transport after use and wiping down the transport cart and bronchoscope display tower
before leaving the room. Wipe down solution should be hydrogen peroxide or equivalent and should be left
wet on all surfaces for at least one minute.
One single-center series from Barcelona, Spain, described their experience in performing bronchoscopy in
mechanically ventilated patients with COVID-19 [108]. Bronchoscopy was performed in both the supine and
prone position and the most common indication was suspected superinfection. Notable was the presence of
significant secretions and mucohematic plugs that were difficult to suction. Approximately one-third had a
new organism identified including Pseudomonas, Staphylococcus, and Klebsiella, similar to typical micro-
organisms identified in patients with ventilator-associated pneumonia. No significant complications were
reported. However, one bronchoscopist out of three became infected with severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2).
Extubation and weaning — Patients are often ready for extubation while they remain infectious, and
because extubation is frequently associated with some coughing, it is considered an aerosol-generating
procedure. Similar to intubation, we encourage the use of extubation protocols and check lists specific to
each institution.
● Weaning – Readiness for extubation should follow standard practice of performing spontaneous
breathing trials (SBT). However, COVID-specific approaches include the following:
• Equipment – We suggest using closed systems and not using a T-piece trial for SBTs.
• SBTs – To reduce the risk of reintubation following extubation, we prefer a higher degree of
readiness in patients with COVID-19. This practice varies and may include higher criteria for
passing an SBT. For example, some experts use lower pressure support ventilation [PSV]
parameters (eg, 0 to 5 cm H2O) rather than the typical 7 cm H2O during the trial while others
promote SBT for longer periods (eg, two to four hours rather than the typical two hours). The
rationale for altered criteria is based upon the observation that patients with COVID-19 are intubated
for longer periods than non-COVID-patients [26] and anecdotal evidence that suggests a high
volume of secretions and airway edema; all of these factors place the patient at high risk of post
extubation respiratory failure requiring reintubation. In addition, we prefer extubating patients directly
to low-flow oxygen rather than high flow oxygen delivered via nasal cannulae (HFNC) or
noninvasive ventilation (NIV), which may risk virus aerosolization. (See "Weaning from mechanical
ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults",
section on 'Daily spontaneous breathing trials (SBTs)' and "Coronavirus disease 2019 (COVID-19):
Infection control in health care and home settings".)
Cuff leak test – Whether the cuff leak test (CLT) should be performed routinely prior to extubation is
unclear. However, its performance may be guided by clinical suspicion for upper airway edema (eg,
fluid overload) or the presence of risk factors for post extubation stridor (eg, prolonged intubation ≥6
days, age >80 years, large endotracheal tube, traumatic intubation). Performing the cuff leak test
should be weighed against the potential risk of aerosolization, and similar to extubation, it should be
preferentially done in an airborne isolation room. In our institution, we routinely administer
glucocorticoids (eg, methylprednisolone 20 mg intravenously every four hours for a total of four
doses) to most patients with COVID-19 before extubation and only extubate those in whom the CLT
is positive after glucocorticoids. We base this practice upon the high rate of airway edema noted in
our population but understand that practice may vary depending upon the population served. (See
"Extubation management in the adult intensive care unit", section on 'Cuff leak'.)
● Extubation – We prefer to perform extubation in an airborne isolation room. Respiratory therapists and
others in the room during extubation should adhere to airborne precautions including N95 masks with
eye protection or equivalent. In general, only two people are needed and extra staff outside the room
should be available to help with additional equipment. Some experts use medications to decrease
coughing (eg, lidocaine via ETT, low-dose opioid bolus, dexmedetomidine, remifentanil if available),
although data to support the routine use of anti-tussives are limited. In the ICU, close communication
with a clinician experienced in intubation regarding the occurrence of extubation in a COVID-19 patient is
prudent, in case rapid reintubation is needed, particularly for patients pre-designated as having a difficult
airway.
Both low-flow and high-flow oxygen systems should be set up and readily available. We drape the
patient’s chest and face with a plastic cover to provide barrier protection between the patient and the
operator (eg, a plastic poncho). We typically put the ventilator in standby mode (or switch off)
immediately prior to extubation. After balloon deflation, extra care should be taken during extubation to
keep the inline suction catheter engaged during cuff deflation and to have another handheld suction
catheter available for the removal of pharyngeal and oral sections. The endotracheal tube should be
removed as smoothly as is feasible during inspiration, and disposed of into a biohazard plastic bag
bundled together with the ventilator tubing, the plastic drape, and tape/ETT holders, and inline suction
catheter. The bag is sealed and disposed of immediately. Further details regarding extubation are
provided separately. (See "Extubation management in the adult intensive care unit", section on
'Extubation equipment and technique'.)
● Post-extubation care – The patient is monitored following the procedure. The threshold to reintubate
patients with postextubation respiratory failure should be low. Postextubation care should support the
application of supplemental oxygen at the lowest fraction of inspired oxygen (FiO2) possible, preferably
via low flow nasal canula. Because patients are often extubated while they remain infectious, we would
advise adhering to a similar approach to oxygen delivery as before intubation. (See "Extubation
management in the adult intensive care unit", section on 'Postextubation management' and 'Oxygenation
targets' above.)
The procedure for palliative extubation should be similar except care following extubation also includes
palliative medication and cessation of neuromuscular blockade.
Precautions for extubation in the OR are provided separately. (See "Safety in the operating room", section on
'COVID-19'.)
Tracheostomy — Reports from experts in the field suggest that many patients fail early attempts at weaning
(eg, within the first week), although this does not appear to predict their eventual ability to wean and
extubate. However, some patients require tracheostomy (in our experience <10 percent of ICU admissions)
[109-111].
● Indications – Indications appear to be similar to non-COVID patients (eg, failed extubation, secretion
management, airway edema, neurological impairment such as that which impairs airway protection).
● Timing – The optimal timing for tracheostomy is unknown in COVID-19 patients. In non-COVID patients,
changes in practice have led to most intensivists performing tracheostomy around day 7 to 10 following
initial intubation. Although most intensivists perform tracheostomy approximately 7 to 10 days following
initial intubation in patients without COVID-19, it seems reasonable to defer tracheostomy in patients
with COVID-19 beyond this time frame. COVID-19 patients appear to require mechanical ventilation
longer than other patients (eg, two to three weeks), but can still be successfully extubated after this
point.
● Procedure – Tracheostomy is considered a high risk procedure for aerosolization.
• Both open and percutaneous tracheostomy procedures are acceptable in COVID patients.
• The exact procedure should be determined in advance and at the discretion of the operator with the
minimum number of personnel.
• To minimize cough, neuromuscular blockade is prudent.
• It is preferable that the procedure be done at the bedside in an airborne isolation room. The
operator should wear appropriate PPE similar to other aerosol generating procedures. The
tracheostomy tube should have the syringe attached for immediate balloon inflation once inserted.
In addition, adapters with inline suction catheters attached is also appropriate. (See 'Precautions'
above and "Coronavirus disease 2019 (COVID-19): Infection control in health care and home
settings".)
• Procedures such as open suctioning, dressing changes, inner cannula care, and tracheostomy
changes are also considered as aerosol-generating. Thus, post tracheostomy care should also
occur in an airborne isolation room, if feasible (if not, consider a portable HEPA-filtration unit).
Novel barrier protections for performing tracheostomy have been proposed. In one report, tracheostomy
was performed under an aerosol-reduction cover with a high-efficiency particulate air filtration unit placed
close to the surgical field [112]. However, no description of aerosol deposition was provided.
● Prolonged weaning – Tracheostomy collar trials can be safely done in an airborne isolation room with
resumption of ventilation and a closed loop system following the trial. However, some institutions use a
portable HEPA filter to generate negative pressure in a room or use closed systems and dual limb
circuitry with a HEPA filter attached to the exhalation limb to minimize environmental contamination. A
surgical mask over the tracheostomy itself may also theoretically limit droplet spread.
Once a patient can breathe for 24 hours on a tracheostomy collar (or similar), they can undergo trials of
a speaking valve and “capping” with the balloon deflated. Placing a speaking valve and capping would
be considered aerosol generating so airborne precautions are warranted. However, once a speaking
valve is in place or the tracheostomy is capped, aerosolization is less of a consideration and is the
equivalent of a patient with a cough and on low flow oxygen and the patients may wear a mask over their
nose and mouth.
Decannulation is considered an aerosol-generating procedure, and provided the patient remains

infectious, all the usual airborne precautions should be taken.
● Repeat testing – Some institutions perform repeat SARS-CoV-2 testing to determine when to
discontinue infection control precautions and inform resource allocation. Whether tracheal or
nasopharyngeal swabs should be used for this purpose is uncertain. If patients are tested and have a
positive test, we continue precautions until two tests collected 24 hours apart are negative; however, it
remains uncertain whether viral RNA detection during recovery reflects transmissible infection. (See
'Precautions' above and "Coronavirus disease 2019 (COVID-19): Infection control in health care and
home settings" and "Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention",
section on 'Viral shedding and period of infectiousness'.) .
Further details regarding tracheostomy are provided separately. (See "Overview of tracheostomy".)
Cardiopulmonary resuscitation — In the event of a cardiac arrest, cardiopulmonary resuscitation (CPR)

should proceed with all members of the team wearing appropriate PPE. Practicing a test run of a COVID-19
patient cardiac arrest is prudent. Bag-mask ventilation should be avoided (if feasible); the ventilator can be
used instead to deliver a respiratory rate of 10 breaths per minute (bpm). Guidance for advanced cardiac life
support and CPR in patients who are prone and cannot be returned to the supine position is provided
separately. (See "Advanced cardiac life support (ACLS) in adults" and "Coronavirus disease 2019 (COVID-
19): Arrhythmias and conduction system disease" and "Coronavirus disease 2019 (COVID-19): Arrhythmias
and conduction system disease", section on 'Patients requiring cardiopulmonary resuscitation (CPR)' and
"Basic life support (BLS) in adults".)
Other interventions — Guidance is lacking regarding other procedures commonly performed in the ICU.
Many intubated patients have routine indications for central venous and arterial access for monitoring and for
vasoactive drug infusion. Grouping standard procedures such as central venous catheter and arterial lines
immediately following intubation is appropriate to minimize the frequency of exposure. The transmission risk
of blood is unknown but likely to be low [106].
Significant pleural effusions and barotrauma appear to be unusual as a manifestation of COVID-19. In

general, emergently indicated procedures and interventions should be performed as indicated, with
appropriate infectious precautions. (See 'Clinical features in critically ill patients' above and "Safety in the
operating room", section on 'COVID-19' and "Coronavirus disease 2019 (COVID-19): Clinical features",
section on 'Clinical manifestations'.)
Transfer of COVID-19 patients should be limited to necessary trips (eg, imaging for a diagnosis that would
change management, travel to an airborne isolation room for high risk aerosol-generating procedures such
as intubation and extubation).
SUPPORTIVE CARE
General supportive care of the critically ill patient with COVID-19 pneumonia is similar to that in patients with
acute respiratory distress syndrome (ARDS) due to other causes and is discussed in detail separately. Select
issues pertinent to COVID-19 are discussed in the sections below. (See "Acute respiratory distress
syndrome: Supportive care and oxygenation in adults", section on 'Supportive care' and "Coronavirus
disease 2019 (COVID-19): Management in hospitalized adults", section on 'COVID-19-specific therapy'.)
Routine measures — The supportive care of mechanically ventilated patients that also apply to patients with
COVID-19 are provided in several linked topics. However, potential differences that may pertain to COVID-19
patients are discussed in this section:
Venous thromboembolism prevention — We agree with the American Society of Hematology and the
Society of Critical Care Medicine that routine pharmacologic venous thromboembolism (VTE) prophylaxis is
warranted, preferably with low molecular weight heparin (LMWH; eg, enoxaparin 40 mg SC once daily),
unless there is a contraindication (eg, bleeding, severe thrombocytopenia). (See "Prevention of venous
thromboembolic disease in acutely ill hospitalized medical adults".)
Because the risk of VTE appears to be higher than usual in this population, use of more aggressive VTE
prophylaxis in the form of increased intensity of a pharmacologic agent (eg, enoxaparin 0.5 mg/kg every 12
hours, unfractionated heparin 7500 units every eight hours) and/or the addition of a mechanical device is
prudent. Markedly elevated D-dimer levels, which correlate with a poor prognosis, are used by some experts
to guide intensification of anticoagulation (eg, >6 times the upper limit of normal). For patients with a
creatinine clearance <30 mL/minute, enoxaparin should be reduced to 30 mg daily or changed to
unfractionated heparin depending on the severity of kidney impairment and patient weight. Fondaparinux is
appropriate in those with heparin-induced thrombocytopenia.
We believe that administering therapeutic anticoagulation (as a form of prophylaxis) may be assessed on an
individual basis. However the indications for therapeutic anticoagulation, outside of documented VTE, are
unclear but may include those with presumed VTE (eg, sudden unexplained deterioration in oxygenation or
hemodynamic instability, acute cor pulmonale) and clotting of vascular devices (eg, venous, arterial devices,
and hemodialysis devices).
Detailed descriptions of the VTE risk and management of COVID-19 patients with hypercoagulability are
provided separately. (See "Coronavirus disease 2019 (COVID-19): Hypercoagulability".)
Sedation and analgesia — Anecdotal evidence suggests that requirements for sedation and analgesia
appear high in mechanically ventilated patients with COVID-19 and that heavy use of sedatives and
analgesic medication is required for ventilator synchrony. In our practice, we target a Richmond Agitation-
Sedation Scale (RASS (table 9)) of -1 to -2 (or similar on a different scoring system), and in patients with
ventilator dyssynchrony, a RASS of -2 to -3. RASS of -4 to -5 are targeted in those with severe dyssynchrony
and those requiring neuromuscular blockade. For those requiring intravenous (IV) infusions, propofol and
fentanyl are generally the preferred agents. However, shortages of sedatives may influence the choice of
agent. We also quickly transition to oral medications, provided that fluid resuscitation is adequate (eg,
oxycodone, hydromorphone, lorazepam, diazepam). Further details regarding indications, daily awakening,
protocols, and dosing are provided separately. (See "Sedative-analgesic medications in critically ill adults:
Selection, initiation, maintenance, and withdrawal" and "Sedative-analgesic medications in critically ill adults:
Properties, dosage regimens, and adverse effects" and "Pain control in the critically ill adult patient".)
Others — Other supportive measures are included here.
● Nutritional support – The same principles of nutrition in non COVID-19 critically ill patients should be
applied to critically-ill COVID-19 patients. We are not proponents of extra protein supplementation,
vitamin C or D supplementation, or trace element supplementation over and above the usual
recommended daily doses. (See "Nutrition support in critically ill patients: An overview" and "Nutrition
support in critically ill patients: Enteral nutrition" and "Nutrition support in critically ill patients: Parenteral
nutrition".)
● Glucose control. (See "Glycemic control and intensive insulin therapy in critical illness".)
● Stress ulcer prophylaxis. (See "Stress ulcers in the intensive care unit: Diagnosis, management, and
prevention" and "Management of stress ulcers".)
● Hemodynamic monitoring. (See "Pulmonary artery catheterization: Indications, contraindications, and

complications in adults" and "Pulmonary artery catheterization: Interpretation of hemodynamic values
and waveforms in adults" and "Novel tools for hemodynamic monitoring in critically ill patients with
shock".)
● Fever management. (See "Fever in the intensive care unit", section on 'Outcomes'.)
● Early physical therapy. (See "Post-intensive care syndrome (PICS)", section on 'Prevention and
treatment'.)
● Ventilator-associated pneumonia precautions. (See "Risk factors and prevention of hospital-acquired

and ventilator-associated pneumonia in adults".)
Monitoring for complications — Critically ill patients with COVID-19 should be followed routinely for the
development of complications associated with critical illness from COVID-19 or extrapulmonary
manifestations of SARS-CoV-2 infection. Only essential personnel should enter the rooms of infected
patients when performing daily examinations, care, and procedures.
Common complications include acute kidney injury, mild transaminitis, cardiomyopathy, pericarditis,
pericardial effusions, arrhythmias, sudden cardiac death, and superinfection (eg, ventilator-associated
pneumonia [VAP]) (see 'Clinical features and complications' above). We suggest that daily laboratory studies
include complete blood count with differential, chemistries, liver function and coagulation studies, arterial
blood gases, ferritin level, D-dimer level, and lactate dehydrogenase. Serial measurement of cardiac
troponins and a low threshold transthoracic echocardiogram may be helpful to evaluate for suspected cardiac
injury.
Daily chest radiographs are not recommended routinely for mechanically ventilated patients with or without
COVID-19. In patients with COVID-19 who are mechanically ventilated, chest radiographs should only be
performed when there is an indication (eg, catheter- or endotracheal tube [ETT]-placement or a relevant
clinical change). Chest computed tomography and other imaging should be limited to those in whom testing
would change management. This rationale is based upon the increased risk of viral shedding with
procedures that require transfer out of the intensive care unit (ICU). (See "Complications of the endotracheal
tube following initial placement: Prevention and management in adult intensive care unit patients", section on
'Reassessment of position'.)
Fluid and electrolytes management — Unless patients have sepsis or volume depletion from high fever or
gastrointestinal losses, we prefer conservative fluid management with buffered or non-buffered crystalloids
typical of that advised for patients with ARDS. (See "Acute respiratory distress syndrome: Supportive care
and oxygenation in adults", section on 'Fluid management' and "Evaluation and management of suspected
sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)' and "Treatment of severe
hypovolemia or hypovolemic shock in adults".)
The management of patients who present with septic shock due to COVID-19 is similar to that in patients
with septic shock from other causes. (See "Evaluation and management of suspected sepsis and septic
shock in adults".)
[113].
Dexamethasone for COVID-19 — We use low-dose dexamethasone (6 mg daily for 10 days or until
discharge) for ICU patients with COVID-19 who require oxygen supplementation. In a large randomized trial,
this dexamethasone regimen reduced mortality among hospitalized patients with COVID-19 who were on
supplemental oxygen, particularly among those who required invasive mechanical ventilation [113]. Use of
dexamethasone and other specific interventions for COVID-19 are discussed in detail elsewhere. (See
"Coronavirus disease 2019 (COVID-19): Management in hospitalized adults", section on 'Dexamethasone'.)
For patients with moderate to severe ARDS (eg, patients with a partial arterial pressure of oxygen/fraction of
inspired oxygen [PaO2:FiO2] <200 mmHg) despite initial management with standard therapies, glucocorticoid
therapy has been recommended at a higher dose (eg, dexamethasone 20 mg IV once daily for five days, and
then 10 mg once daily for five days). It is not known whether this would be of additional benefit to the dose of
dexamethasone advised for COVID-19. (See "Acute respiratory distress syndrome: Supportive care and
oxygenation in adults", section on 'Glucocorticoids'.)
Patients with COVID-19 may require ICU level care for comorbidities such as asthma, eosinophilic
pneumonia, COPD, adrenal insufficiency, or rheumatic disease. In some of these patients, it may be
reasonable to tailor glucocorticoid use to the predominant indication.
While low dose glucocorticoids (eg, hydrocortisone 200 to 400 mg/day in divided doses) are indicated for
selected patients with shock that is refractory to fluid resuscitation [7], no additional hydrocortisone is needed
for patients who are receiving dexamethasone for COVID-19 related respiratory failure. The use of
glucocorticoids in septic shock is discussed separately. (See "Glucocorticoid therapy in septic shock in
adults", section on 'Administration'.)
COVID-19 specific therapy — Several investigational agents have been proposed, including off label use of
thrombolytic agents [114]. Individual institutions should work with their pharmacists to develop protocols for
the off-label use of select agents and enrollment of patients in clinical trials. This area is rapidly evolving and
is discussed in detail separately. (See "Coronavirus disease 2019 (COVID-19): Management in hospitalized
adults", section on 'COVID-19-specific therapy'.)
Nebulized medication — Nebulization is considered an aerosol-generating procedure. For patients with

COVID-19 who are intubated and require bronchodilators for an evidence-based indication (eg, acute
bronchospasm from asthma or chronic obstructive lung disease exacerbation), we prefer the use of in-line
metered dose inhalers (MDIs; ie, pressurized inhalers) rather than administration via a standard jet or
vibrating mesh nebulizer due to the lower risk of aerosolization associated with MDIs [115,116].
For medications that can only be administered via a nebulizer, consideration should be given to stopping the
medication if it is not essential for acute care (eg, inhaled colistin for patients with bronchiectasis) or using an
MDI alternative, if available on formulary (eg, tobramycin capsule inhaler). Consideration should be given to
the patient using their own supply if MDIs are not on formulary.
Placement of a filter at the expiratory port of the ventilation circuit during nebulization is prudent to minimize
aerosolization into the room. Ideally, patients who require nebulizers, should be in an airborne infection
isolation room. Only the healthcare staff necessary for nebulizer administration (eg, respiratory therapists or
nurse) should be in the room for the initiation of the procedure and airborne precautions similar to those for
intubation should be taken. (See 'The decision to intubate' above and "Coronavirus disease 2019 (COVID-
19): Infection control in health care and home settings".)
Management of co-infections and comorbidities — Critically ill patients with COVID-19 who are intubated
are at risk for developing VAP and other infections typical of all critically ill and/or intubated patients (eg,
central line or urinary tract infections). When treating co-infections, potential drug interactions with any
investigational COVID-19 agent should be assessed. Infectious disease experts should be involved early in
the management of COVID-19 patients who are critically ill. Further details regarding management of chronic
medications including nonsteroidal anti-inflammatories and angiotensin receptor inhibitors are provided
separately. (See "Coronavirus disease 2019 (COVID-19): Management in hospitalized adults", section on
'Uncertainty about NSAID use' and "Coronavirus disease 2019 (COVID-19): Management in hospitalized
adults", section on 'Managing chronic medications'.)
SPECIAL POPULATIONS
There are no specific recommendations for pregnant women who are critically-ill with COVID-19 pneumonia.
Management should be similar to uninfected patients. Issues regarding transmission and risk of acquiring
SARS-CoV-2 in pregnant women is described separately. (See "Critical illness during pregnancy and the
peripartum period" and "Acute respiratory failure during pregnancy and the peripartum period" and
"Coronavirus disease 2019 (COVID-19): Pregnancy issues" and "Coronavirus disease 2019 (COVID-19):
Clinical features", section on 'Pregnant and breastfeeding women'.)
In patients with sickle cell disease who are critically-ill with COVID-19 in whom acute chest syndrome is
contributing to their illness, consideration of early exchange transfusions and surveillance for the
development of acute pulmonary hypertension is prudent [117]. (See "Acute chest syndrome in adults with
sickle cell disease", section on 'COVID-19'.)
Issues that arise for other populations are provided in the following links:
● Renal issues (see "Coronavirus disease 2019 (COVID-19): Issues related to kidney disease and
hypertension")
● Cardiac issues (see "Coronavirus disease 2019 (COVID-19): Myocardial infarction and other coronary
artery disease issues" and "Coronavirus disease 2019 (COVID-19): Arrhythmias and conduction system
disease" and "Coronavirus disease 2019 (COVID-19): Myocardial injury")
● Airway management and operating room issues (see "Coronavirus disease 2019 (COVID-19):
Anesthetic concerns, including airway management and infection control")
● Cancer care (see "Coronavirus disease 2019 (COVID-19): Screening, diagnosis, and treatment of
cancer in uninfected patients during the pandemic")
PROGNOSIS
Mortality — Data are evolving describing outcomes from COVID-19 in critically ill patients who develop
acute respiratory distress syndrome (ARDS) [2,10-12,24-26,28,30,31,34,35,37,38,118]. Mortality appears
lower than that in patients with severe acute respiratory syndrome (SARS-CoV) or Middle East respiratory
syndrome (MERS). The mortality from COVID-19 appears driven by the presence of severe ARDS, and has
been reported over a wide range (range 12 to 78 percent). Mortality may be decreasing as the pandemic
progresses [24,119].
● In a single-center retrospective cohort of 52 critically ill Chinese patients with COVID-19, 62 percent had
died by 28 days with a median duration of only seven days from intensive care unit (ICU) admission to
death [11]. Among the 20 patients who survived, three remained on mechanical ventilation, three were
receiving noninvasive mechanical ventilation or high flow oxygen via nasal cannulae (HFNC), and six
were receiving low flow oxygen.
● In a retrospective cohort of 201 Chinese patients with COVID-19, the mortality was 52 percent among
those who developed ARDS [30]. Among those who received mechanical ventilation, 66 percent died, 21
percent were discharged and 13 percent remained hospitalized.
● In a preliminary study of 21 critically ill patients in the United States, by day 5, 67 percent of critically ill
patients had died, 24 percent remained critically ill, and 9.5 percent were discharged from the ICU [22].
● In an Italian cohort of 1591 patients, the ICU morality was 26 percent, but a significant proportion
remained in the ICU at the time of the publication, which may have underestimated the true mortality
[26].
● In an analysis of patients during a resurgence of COVID-19 in Houston, Texas, in-hospital mortality was
lower during the second surge compared to the first surge (5 versus 12 percent) but the difference in
ICU mortality was not significant (23 versus 28 percent) [24]. These data may be reflective of a patient
population that was younger and had a lower comorbidity burden during the second surge or growing
expertise with COVID-19 care.
Higher mortality was initially reported in males compared with females but this may have been due to the
predominance of males affected with COVID-19 in the Chinese cohorts [10-12,30,31]; a similar difference
has been noted in the preliminary reports from Italy but not from Washington state, USA [21,22].
Risk factors for death — Across countries, the consistent major risk factor associated with death in critically
ill patients with COVID-19 is older age [11,12,20,23,26,28,30,38,118,120,121]. In two Chinese retrospective
cohorts, death from ARDS was more likely to occur in those of older age ≥64 years (hazard ratio [HR] 6.17;
95% 3.26-11.67) [11,30]. Preliminary reports from Italy and the United States are reporting similar outcomes
[20,21,23,38]. Other risk factors associated with death among critically ill patients include the following
[11,12,20,23,26,28,30,118,122,123]:
● The development of ARDS, particularly severe ARDS, and the need for mechanical ventilation
● Comorbidities (eg, chronic cardiac and pulmonary conditions, hypertension, diabetes, chronic kidney
disease)
● Markers of inflammation or coagulation (eg, D-dimer level >1 microg/mL admission, elevated fibrin
degradation products, prolonged activated partial thromboplastin and prothrombin times)
● Select laboratory studies (eg, worsening lymphopenia, neutrophilia, troponin leak)
The rapidity of symptom progression does not appear to predict a worse outcome [11]
While high fever was associated with a higher likelihood of developing ARDS (HR 1.77; 95% CI 1.11-2.84), it
appears to be associated with a lower likelihood of death (HR 0.41; 95% CI 0.21-0.82) [11,30], a
phenomenon that has been noted previously in some critically ill patients. (See "Fever in the intensive care
unit", section on 'Outcomes'.)
Further details on the risk factors associated with severe disease are provided separately. (See 'Risk factors
for progression' above.)
Long term sequelae — The percentage of patients that require long term care is unreported. Similarly, the
incidence of critical care neuromyopathy is not yet documented. In our experience the rate may be higher
than usual due to the prolonged nature of intubation in COVID-19 patients and higher use of neuromuscular
blockade and sedatives, with or without concurrent glucocorticoid administration. (See "Neuromuscular
weakness related to critical illness".)
The incidence of post-intensive care unit syndrome (PICS) or ARDS sequelae is also unknown in COVID-19
patients. Nonetheless, patients should be followed and treated for PICS which involves nutritional, physical,
psychological, and occupational therapy. (See "Post-intensive care syndrome (PICS)".)
One retrospective study of 110 patients with COVID-19 reported persistent abnormalities in lung function
upon discharge in patients with mild illness pneumonia, and severe pneumonia [124]. The most common
abnormalities were reduced diffusion capacity and restriction. Abnormalities were most prevalent in those
with severe pneumonia. However, critical care cases were excluded from the analysis, and the study lacked
baseline data to inform risk for developing abnormal lung function and followup data to inform the trajectory
of lung function during recovery.
END OF LIFE ISSUES
In a public health emergency, values other than autonomy predominate. Like any critical illness, severe
illness due to COVID-19 carries the potential of significant psychosocial distress to patients, families, and
surrogates. In addition, unique aspects of COVID-19 and its management portend greater trauma including
anxiety and stigma surrounding a novel pathogen and high-level isolation precautions including visitation
limitation or prohibition including at the end of life. High levels of patient, family, and surrogate psychosocial
distress should be anticipated and combatted with clear communication strategies and early palliative care
involvement (table 10). Even if in-person visitation is not allowed due to public health care concerns,
hospitals should promote internet based visual communication such as video communication between
clinicians, families, and isolated patients.
Discussing end-of-life wishes with patients and their family should occur early in the course of management,
including potentially even before diagnosis, especially in light of the poor outcomes for elderly patients with
comorbidities who develop acute respiratory distress syndrome (ARDS) and require mechanical ventilation
[125]. Consultation with the palliative care teams and ethic experts should also be done to assist families in
decision-making and assist clinicians with contentious issues or disagreement that may arise.
Due to the unique aspects to addressing needs of patient and families in this pandemic, several online
resources are available for clinicians to use when having COVID-19 specific discussions with patients and
families. They provide helpful language and strategies for conversations about a range of issues including,
but not limited to, triaging, discussing goals of care, resource allocation, and grieving including:
● VIITALtalk
● Center to Advance Palliative Care
● National Coalition for Hospice an Palliative Care
Further principles regarding ethical issues in the intensive care unit (ICU) and advance care planning are
discussed separately. (See "Ethics in the intensive care unit: Responding to requests for potentially
inappropriate therapies in adults" and "Ethics in the intensive care unit: Informed consent" and "Withholding
and withdrawing ventilatory support in adults in the intensive care unit" and "Communication in the ICU:
Holding a family meeting" and "Palliative care: Issues in the intensive care unit in adults" and "Advance care
planning and advance directives", section on 'COVID-19 resources'.)
DISCHARGE, RECOVERY, AND LONG TERM CARE
For patients who extubate successfully and can be discharged home, routine community precautions apply
(see "Coronavirus disease 2019 (COVID-19): Infection control in health care and home settings", section on
'Discontinuation of precautions'). Follow-up imaging is appropriate, although no guidelines are provided to
facilitate when imaging should be performed. Extrapolating from patients who have community acquired
pneumonia, it is reasonable that imaging with chest radiography be performed at 12 weeks following
discharge to ensure resolution of infiltrates. Chest radiograph should also be obtained in patients with new or
worsening respiratory symptoms that might suggest a complication (eg, secondary bacterial infection or
parapneumonic effusion). Obtaining chest computed tomography is not necessary unless patients had
imaging abnormalities during their illness that were concerning for another pathology (eg, incidental nodule,
interstitial lung disease, bronchiectasis), or the patient has persistent respiratory symptoms weeks after
recovery. Long term pulmonary function outcomes from severe COVID-19 or COVID-related acute
respiratory distress syndrome (ARDS) are unknown. Nonetheless, extrapolating from the ARDS population,
pulmonary function tests (PFTs) should be performed at 12 weeks following discharge. If PFT abnormalities
are present, obtaining followup PFTS yearly thereafter for five years is appropriate. (See "Acute respiratory
distress syndrome: Prognosis and outcomes in adults", section on 'Lung function' and "Treatment of
community-acquired pneumonia in adults who require hospitalization", section on 'Radiographic response'.)
For patients who require a tracheostomy or are deconditioned from critical illness, transfer to a long term
acute care (LTAC) facility is typical. However, there is no guidance on whether or when patients should be re-
tested. Many, but not all, LTACs require two negative SARS-CoV-2 RT-PCR tests performed 24 hours apart
before accepting a patient with COVID-19. If positive testing delays transfer to an LTAC, continued infection
control precautions are advised, and rehab and weaning should begin at the acute care facility. Outcomes in
patients who require long term care are unknown. Treatment of patients who require admission to an LTAC
should be similar to non-COVID patients. Particular attention should be paid to continuing venous
thromboembolism prophylaxis until the acute illness fully resolves or the patient become mobile, although the
efficacy of this approach is unknown. Duration of therapeutic anticoagulation should be guided by the
indication; for example, a minimum of three months for documented or presumed VTE is appropriate while
shorter durations are reasonable for device thrombosis. Follow up imaging in this population is also
reasonable upon admission to the LTAC facility and periodically thereafter depending on the success of
weaning and rate of recovery. PFTs are not feasible in the ventilated patient but should be performed
following weaning and rehabilitation prior to discharge. The management of patients who require long term
mechanical ventilation is discussed separately. (See "Management and prognosis of patients requiring
prolonged mechanical ventilation".)
SURGE CAPACITY AND SCARCE RESOURCE ALLOCATION
COVID-19 is a global pandemic and has placed significant increases in demand for acute and critical care
services on hospitals in many regions. This has necessitated operations maneuvers to increase capacity to
be able to provide care for more patients, for higher acuity patients requiring intensive care unit (ICU)
admission and mechanical ventilation, and for patients with special isolation requirements. Surge capacity
may be achieved by maximizing resources across three domains:
● Care spaces (ie, beds)

● Staff
● Physical equipment
In the COVID-19 pandemic, this has included expanding ICU care into non-ICU spaces, utilizing non-critical
care trained staff to participate in delivering critical care, and innovative approaches to obtain, conserve, and
increase the efficiency of physical equipment including personal protective equipment (PPE; eg, repeat use
of N95 masks) and mechanical ventilators (eg, double ventilation, repurposing operating room ventilators).
As an example, some experts have published preliminary data to highlight the use of one ventilator for use in
multiple patients [126]. However, this maneuver was designed for a disaster setting where one might
reasonably expect that several patients might need life support at similar levels. Use of this measure as a
life-saving measure in patients with COVID-19 could be complicated if patients are not matched well in terms
of their ventilator settings. Potential use of anesthesia ventilators for longer-term mechanical ventilation is
provided separately. (See "Coronavirus disease 2019 (COVID-19): Intensive care ventilation with anesthesia
machines".)
In some instances, such as in Italy, despite mobilizing to surge capacity, demand for care has still outpaced
supply such that overt rationing has occurred [127]. All hospitals facing the potential of an acute surge event
due to COVID-19 or another insult should have a process to approach the allocation of scarce resources
such as ICU beds and mechanical ventilators [128,129]. Most individual states in the United States have
guidance documents which can be adapted for local institutions [128]. General principles that guide and
underpin scarce resource allocation policies include:
● Maximization of lives saved and/or life-years saved

● Transparency
● Stakeholder and public input
● Separation between the clinical team and the triage process (eg, ethics committees for difficult triage
decisions)
● Robust palliative care and supportive measures for patients who are not provided with critical care
resources
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Coronavirus disease 2019 (COVID-19) – International
public health and government guidelines" and "Society guideline links: Coronavirus disease 2019 (COVID-
19) – Guidelines for specialty care" and "Society guideline links: Coronavirus disease 2019 (COVID-19) –
Resources for patients".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer
the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable
with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Coronavirus disease 2019 (COVID-19) overview (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Among patients hospitalized with coronavirus disease 2019 (COVID-19), up to one-quarter require
intensive care unit (ICU) admission. (See 'Introduction' above and 'Epidemiology' above.)
● Profound hypoxemic respiratory failure from acute respiratory distress syndrome (ARDS) is the dominant
finding in critically ill patients. Common complications include acute kidney injury (AKI), elevated liver
enzymes, and the late development of cardiac injury, including sudden cardiac death. Sepsis, shock, and
multi-organ failure are less common. (See 'Clinical features in critically ill patients' above.)
● For most critically ill patients with COVID-19, we prefer the lowest possible fraction of inspired oxygen
(FiO2) necessary to meet oxygenation goals, ideally targeting a peripheral oxygen saturation between 90
and 96 percent. (See 'Respiratory care of the nonintubated patient' above and 'Oxygenation targets'
above and 'Low flow oxygen' above.)
• The decision to initiate noninvasive modalities, high-flow oxygen via nasal cannulae (HFNC) and
noninvasive ventilation (NIV), requires balancing the risks and benefits to the patient, the risk of
exposure to healthcare workers, and best use of resources. In patients with COVID-19 who have
acute hypoxemic respiratory failure and higher oxygen needs than low flow oxygen (eg, >6L/minute)
can provide, we suggest noninvasive measures rather than routinely proceeding directly to
intubation (Grade 2C).
• Among the noninvasive modalities we suggest HFNC rather than NIV (Grade 2C). Our preference
for HFNC is based upon limited and inconsistent data, which, on balance, favors HFNC compared
with NIV in patients with non-COVID-19-related acute hypoxemic respiratory failure. NIV via a full
face mask (with a good seal) may be appropriate in patients with indications that have proven
efficacy including acute hypercapnic respiratory failure from an acute exacerbation of chronic
obstructive pulmonary disease, acute cardiogenic pulmonary edema, and sleep disordered
breathing. (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations
and potential applications", section on 'Medical patients with severe hypoxemic respiratory failure'
and "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications",
section on 'Patients likely to benefit'.).
• For patients with COVID-19 who receive HFNC or NIV, vigilant monitoring is warranted for
progression with frequent clinical and arterial blood gas evaluation every one to two hours to ensure
efficacy and safe ventilation. Encouraging prone positioning is also appropriate. The threshold to
intubate such patients should be low.
● For critically ill patients with COVID-19, intubation should not be delayed until the patient acutely
decompensates since this is potentially harmful to both the patient and healthcare workers. We have a
low threshold to intubate those who have (see 'Timing' above):
• Rapid progression over a few hours

• Failure to improve despite HFNC >50 L/min and FiO2 >0.6
• Development of hypercapnia
• Hemodynamic instability or multiorgan failure
● Intubation is a high risk procedure for aerosol dispersion in patients with COVID-19 and attention should
be paid to donning full personal protective equipment (PPE) with airborne precautions (figure 2 and
figure 3) as well using equipment that minimizes dispersion (eg, video laryngoscopy) and the
development of protocols for the procedure (eg, check lists) (table 2 and figure 1). (See 'Precautions'
above and "Safety in the operating room", section on 'COVID-19'.)
● We use low tidal volume ventilation (LTVV) targeting ≤6 mL/kg predicted body weight (PBW) (range 4 to
8 mL/kg PBW (table 3 and table 4)) that targets a plateau pressure ≤30 cm H2O and applies positive
end-expiratory pressure (PEEP) according to the strategy outlined in the table (table 5). For patients with
COVID-19 who fail LTVV, prone ventilation is the preferred next step (table 7 and table 6). (See
'Ventilator management of acute respiratory distress syndrome' above and "Ventilator management
strategies for adults with acute respiratory distress syndrome" and "Prone ventilation for adult patients
with acute respiratory distress syndrome" and "Extracorporeal membrane oxygenation (ECMO) in
adults".)
● Several procedures, including the collection of respiratory specimens, bronchoscopy, extubation,

tracheostomy, and cardiopulmonary resuscitation are aerosol-generating and should be avoided or
minimized, if possible. All procedures should be grouped when possible. (See 'Interventions' above.)
● Patients with COVID-19 pneumonia who are mechanically ventilated for ARDS should receive the usual
daily surveillance, and supportive care including conservative fluid management (unless patients have
sepsis or volume depletion) (table 1). Measurement of surveillance cardiac troponins and a low threshold
to perform transthoracic echocardiography is appropriate for the early detection of cardiac injury. (See
'Supportive care' above and 'Monitoring for complications' above.)
• We use low-dose dexamethasone for ICU patients with COVID-19 who require oxygen
supplementation or mechanical ventilation, based on accumulating evidence that glucocorticoids
reduce mortality in such patients. The dose of dexamethasone is 6 mg daily for 10 days or until
discharge, if sooner. Use of dexamethasone and other specific interventions for COVID-19 are
discussed in detail elsewhere. (See "Coronavirus disease 2019 (COVID-19): Management in
hospitalized adults", section on 'COVID-19-specific therapy'.)
• For acute bronchodilation, we prefer the use of in-line metered dose inhalers (MDIs) rather than
administration via a standard jet or vibrating mesh nebulizer due to the lower risk of aerosolization
associated with MDIs. Individual institutions should work with their pharmacy regarding
compassionate use of investigational medications and trial enrollment. We suggest the development
of protocols by individual ICUs for the off-label use of investigational agents. (See 'Nebulized
medication' above and "Coronavirus disease 2019 (COVID-19): Management in hospitalized
adults", section on 'COVID-19-specific therapy'.)
● For patients with COVID-19 who develop ARDS, the prognosis is poor with mortality ranging from 52 to
67 percent. The highest rates of death occur in those ≥64 years. (See 'Prognosis' above.)
● A greater level of anxiety and trauma among patients and families should be anticipated and combatted
with clear communication strategies and early palliative care involvement (table 10). Precautions should
continue if the patient continues to test positive for COVID-19 before discharge to a long term acute care
facility. (See 'End of life issues' above and 'Discharge, recovery, and long term care' above.)
● Several measures should be adopted to accommodate a surge in COVID-19 cases including included
expanding ICU care into non-ICU spaces, utilizing non-critical care trained staff to participate in
delivering critical care, and innovative approaches to obtain, conserve, and increase the efficiency of
physical equipment (eg, personal protective equipment and mechanical ventilators). (See 'Surge
capacity and scarce resource allocation' above.)
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Topic 127419 Version 70.0

GRAPHICS
Rapid overview of initial ICU management of patients with suspected COVID-19 infection
ENHANCED PRECAUTIONS: N95 mask* (or equivalent), gloves, gown, eye protection; disposable
stethoscope; airborne infection isolation room for aerosol-generating procedures
Diagnostic testing Actions Explanatory notes
Nasopharyngeal swab Perform SARS-CoV-2 (COVID-19) test Oropharyngeal swab is an alternative if

Test for influenza if prevalent in the nasopharyngeal swab is not available.
community In intubated patients, tracheal aspirates and
Do NOT obtain viral cultures nonbronchoscopic alveolar lavage ("mini-
BAL") are also acceptable.
Bronchoscopy is only performed for this
indication when upper respiratory samples
and mini-BAL are negative.
Other microbiology Obtain the following:

Blood cultures
Sputum culture, if clinically indicated
(avoid induced sputum)
Urinary antigen for Legionella,
Pneumococcus, if clinically indicated
Baseline laboratory testing Obtain the following: ¶ Neutrophilia is uncommon while

CBC with differential counts lymphopenia is common, resulting in a high
Urinalysis ratio (>50) of neutrophils:lymphocytes.
Chemistry panel including LFTs Elevated LFTs are common.
Troponin and BNP at baseline, and Procalcitonin is often low early in illness.
subsequently as indicated Lymphopenia and elevation of LDH, ferritin,
Biomarkers at baseline and for interval and CRP are associated with disease
monitoring: procalcitonin, ferritin, CRP, progression and need for mechanical
CPK, D-dimer, triglycerides, fibrinogen, ventilation.
LDH
Imaging Obtain portable chest radiograph Main role of POC ultrasound is to identify
POC ultrasound may provide additional other causes of respiratory compromise (eg,
information pneumothorax, pleural effusion, pericardial
CT only in patients with an indication that effusion, heart failure) or other contributors
would change management to hypotensive shock.
Characteristic findings on POC ultrasound in
COVID-19 pneumonia are nonspecific and
include pleural thickening and B lines.
ECG Baseline at admission Medications that can prolong QTc include

Subsequent daily ECG for patients on (among others): azithromycin,
medications that can prolong QTc hydroxychloroquine, remdesivir,
phenothiazines, quetiapine.
Flexible bronchoscopy Avoid bronchoscopy to prevent aerosol Bronchoscopy, should only be performed for
spread the diagnosis of COVID-19 when upper
If necessary, perform in airborne infection respiratory samples and mini-BAL are
isolation room negative or when indicated for another
reason (eg, infection in an
immunosuppressed patient; life-threatening
hemoptysis or airway obstruction).
Supportive care Actions Explanatory notes

Management is largely supportive with surveillance for common
complications including ARDS, acute kidney injury, elevated liver enzymes,
and cardiac injury. All co-infections and comorbidities should be managed.
Patients should be monitored for prolonged QTc interval and for any drug
interactions.
Goals of care Recommend early discussion and

involvement of palliative care team as
necessary
Vascular access Place central venous catheter
Place arterial line if frequent need for ABGs
anticipated (eg, ventilated patient with
ARDS)
Bundle procedures to minimize exposure;
review procedure checklist before entering
room
Intravenous fluids and Conservative approach. Use vasopressors

nutrition preferentially rather than large volume (>30
mL/kg) IV fluid resuscitation.
Follow standard ICU protocols for nutritional
support
Nebulizer treatments Avoid nebulizers whenever possible to If MDIs are not available, the patients may
prevent aerosol spread be able to use their own supply.
Use MDIs for inhaled medications (including
patients on mechanical ventilation)
When required for some patients with
asthma and COPD exacerbation, give
nebulizers in an airborne infection
isolation room
Oxygen/respiratory Goal SpO 2 90 to 96% For ventilated patients, some experts aim
support May give NC up to 6 L/minute or NRB up to for higher SpO 2 target to minimize entry to
10 L/minute the room.
Use of HFNC and NIV is controversial; early Some experts advocate placing a surgical
intubation may be preferred for mask on patients wearing low-flow oxygen
decompensating patients. Each institution devices, although the efficacy of this
should have a policy outlining management approach is unclear. It may be appropriate if
approach. the patient is not in an airborne isolation
HFNC and NIV increase risk of room or during transport.
aerosolization; use surgical mask over
HFNC or NIV interfaces
HFNC is generally preferred over NIV,
except for acute hypercapnia due to
COPD exacerbation or ACHF
Reassess patients on HFNC and NIV
every 1 to 2 hours, or sooner if SpO 2
<90 or clinical deterioration
Tracheal intubation Actions Explanatory notes

and mechanical
ventilation
Indications Signs of respiratory distress (eg, accessory

muscle use; paradoxical abdominal
breathing)
Rapid progression of disease
SpO 2 sat <90% despite maximal
supplemental oxygen
Arterial pH <7.3 with PaCO 2 >50
Patient requiring >40 L/minute HFNC and
FiO 2 >0.6
Hemodynamic instability; multiorgan failure
Rapid sequence intubation Performed by experienced intubator

Avoid bag valve mask ventilation: If must
perform, use in-line bacterial/viral filter; 2-
person technique improves seal and reduces
aerosolization.
Ventilator settings Provide low tidal volume ventilation: ARDSNet provides a guide to PEEP and FiO 2
AC with TV target 6 mL/kg PBW (range 4 titration; refer to UpToDate text for details.
to 8 mL/kg PBW)
RR 25 to 30 to start; goal 10 to 15
breaths/minute
PEEP/FiO 2 : PEEP 10 to 15 cm H 2 O to
start
Titrate oxygen to target PaO 2 55 to
80/SpO 2 90 to 96 for most patients
Plateau pressure <30 cm H 2 O
Δ
Goal pH >7.15 Δ
Prone ventilation Suggest prone positioning should low tidal Effects of prone ventilation typically seen
volume ventilation fail (eg, PaO 2 /FiO 2 [P/F] over 4 to 8 hours; improvements continue
ratio <150 mmHg × 12 hours or worsening the longer it is used.
oxygenation after intubation)
Advise prone position for 12 to 16 hours/day
Need experienced staff; ensure that ETT and
vascular access remain secured when
turning
Additional rescue For patients who fail prone ventilation (eg, Please refer to UpToDate topic text for
therapies P/F ratio <150 mmHg while prone), may details on how to perform recruitment
consider the following interventions: maneuvers and administer higher than usual
Recruitment maneuvers and high PEEP levels of PEEP.
strategies Pulmonary vasodilators should not be
Trial of inhaled pulmonary vasodilators administered unless a specific protocol and
such as NO/epoprostenol staff experienced in their administration are
Neuromuscular blockade for patients with in place. Inhaled vasodilators may increase
refractory hypoxemia (eg, P/F <100 aerosolization.
mmHg) or ventilator dyssynchrony
ECMO as a last resort; however, ECMO is
not universally available
Pharmacotherapy Actions Explanatory notes

Implement ICU protocols for sedation, analgesia, neuromuscular blockade (if
needed), stress ulcer prophylaxis, thromboembolism prophylaxis, glucose
control
Empiric antibiotics For suspected bacterial co-infection (eg,

elevated WBC, positive sputum culture,
positive urinary antigen, atypical chest
imaging), administer empiric coverage
for community-acquired or healthcare-
associated pneumonia
Investigational agents COVID-19 specific therapy, including Refer to other UpToDate content for details.
Remdesivir, should be considered. Therapies
are evolving.
Systemic glucocorticoids Consider dexamethasone 6 mg (oral or IV) Refer to other UpToDate content for details.
daily for 10 days
Give glucocorticoids for other indications
(eg, asthma, COPD), as indicated
Adjustments to Actions Explanatory notes

outpatient meds
Assess and seek expert consultation to manage comorbid conditions
(asthma, COPD, sickle cell disease, immunocompromise, pregnancy)
ICS For asthma, continue usual dose

For COPD without asthmatic component or
clear prior benefit, hold ICS
For COPD with asthmatic component or
clear prior benefit, continue ICS
Oral glucocorticoids If taking as outpatient: Adjust dosing to

prevent adrenal insufficiency
If asthma/COPD flare: Use per usual
indications
NSAIDs Acetaminophen is preferred antipyretic There are minimal data informing the risks
of NSAIDs in the setting of COVID-19. Given
the uncertainty, we use acetaminophen as
the preferred antipyretic agent.
ACEi/ARBs Continue if there is no other reason for

discontinuation (eg, hypotension, acute
kidney injury)
Statins Patients taking a statin at baseline should

continue
ICU: intensive care unit; BAL: bronchoalveolar lavage; CBC: complete blood count; LFTs: liver function tests; CRP: C-reactive protein;
CPK: creatinine phosphokinase; LDH: lactate dehydrogenase; IL: interleukin; POC: point of care; CT: computed tomography; ECG:
electrocardiogram; QTc: rate-corrected QT interval; ARDS: acute respiratory distress syndrome; ABGs: arterial blood gasses; IV:
intravenous; MDIs: metered dose inhalers; COPD: chronic obstructive pulmonary disease; SpO 2 : pulse oxygen saturation; NC: nasal
cannula; NRB: non rebreather; HFNC: high flow nasal cannula; NIV: noninvasive ventilation; ACHF: acute congestive heart failure;
FiO 2 : fraction of inspired oxygen; AC: assist controlled; TV: tidal volume; PBW: ideal predicted body weight; RR: respiratory rate;
PEEP: positive end-expiratory pressure; ETT: endotracheal tube; NO: nitric oxide; ECMO: extracorporeal membrane oxygenation; WBC:
white blood count; CAP: community acquired pneumonia; MRSA: methicillin-resistant Staphylococcus aureus; ICS: inhaled
corticosteroids; NSAIDs: nonsteroidal anti-inflammatory agents; ACEi: angiotensin converting enzyme inhibitors; ARBs: angiotensin
receptor blockers; ESR: erythrocyte sedimentation rate.
* The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) note that a medical/surgical mask is an
alternative in the absence of aerosol generating procedures (AGP) if N95 mask is not available.
¶ Evidence suggests that a subgroup of patients with severe COVID-19 may be eligible for immune suppression with tocilizumab in the
setting of a trial or compassionate use. The rationale is that COVID-19 may have cytokine release syndrome (CRS) or a CRS-like
presentation as suggested by organ failure, increasing ferritin, CRP, LDH, erythrocyte sedimentation rate, thrombocytopenia, and
lymphopenia. Administration of tocilizumab warrants discussion with a subspecialist and eligible patients may need an interleukin-6
level measured. Troponins may be measured daily or as indicated if cardiac dysfunction is suspected. Triglycerides should be measured
when patients are on propofol for sedation. Marker of disseminated intravascular coagulopathy including activated partial
thromboplastin, activated thrombin, D-dimer, and fibrinogen are also regularly monitored as are LFTs and a complete blood count and
differential.
Δ Refer to UpToDate text on ventilator management strategies for adults with acute respiratory distress syndrome for information about
permissive hypercapnia during low tidal volume ventilation.
References:
1. FACTT Algorithm: Composite Protocol-Version 2. http://www.ardsnet.org/files/factt_algorithm_v2.pdf (Accessed April 1, 2020).
2. Barrot L, Asfar P, Mauny F, et al. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med
2020; 382:999.
3. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;
368:2159.
4. Sickle Cell Disease and COVID-19: An Outline to Decrease Burden and Minimize Morbidity.
https://www.sicklecelldisease.org/files/sites/181/2020/03/SCDAA-PROVIDER-ADVISORY4-3-25-20-v2.pdf (Accessed April 1,
2020).
5. Pregnancy & Breastfeeding: Information about Coronavirus Disease 2019. https://www.cdc.gov/coronavirus/2019-ncov/need-
extra-precautions/pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-
ncov%2Fprepare%2Fpregnancy-breastfeeding.html (Accessed April 1, 2020).
Graphic 127595 Version 5.0
Pendant reservoir cannula
Oronasal mask
Oronasal mask (Spectrum, Respironics, Inc) adapted for use with noninvasive
positive pressure ventilation. To prevent rebreathing in the case of ventilator
failure, the mask incorporates an "anti-asphyxia" valve and a quick-release
strap.
Oronasal mask
From: Bachour A, Avellan-Hietanen H, Palotie T, Virkkula P. Practical Aspects of

Interface Application in CPAP Treatment. Can Respir J 2019. Available at:
https://www.hindawi.com/journals/crj/2019/7215258/. Copyright © 2019 The
Authors. Reproduced under the terms of the Creative Commons Attribution License
4.0.
Tracheal intubation of COVID-19 patients outside the OR: Guidelines and modifications
Key principles
Maximize first-attempt success while keeping patients and providers safe.

Prevent contamination and spread of virus. There is a high risk of aerosolization of virus during airway management.
RSI steps (seven P's) Important actions and modifications
Preparation Use checklist adapted for COVID-19 patients. Placing required airway equipment and
medications in prepackaged bundles may be helpful.
Review airway plan as a team before entering room. RSI preferred whenever possible. Avoid
awake intubation (cough during awake intubation increases viral spread).
Prepare all required equipment and draw up and label all medications (including induction
agent, NMBA, vasopressor [eg, norepinephrine infusion], isotonic IVF) before entering
intubation room.
Keep all nonessential equipment just outside room.
Have available all standard airway equipment plus:

Bag-mask with HEPA filter
Video laryngoscope with clear, disposable cover for the device
Ventilator and tubing with in-line adaptors (for suctioning and bronchoscopy) and
HEPA filters
Waveform capnography if available
Smooth clamp for ETT
Use negative-pressure room for intubation whenever possible.
Limit intubation team in room to 3 members: intubator; nurse or other clinician; respiratory
therapist.
If possible, second intubator wearing PPE should remain outside room to assist with anticipated
difficult airway or as necessary.
Before entering room:

Perform hand hygiene.
Don PPE with proper technique and supervision. PPE should include:
N95 respirator or PAPR
Eye protection (goggles, face shield that covers front and sides of face, or full face
PAPR)
Double gloves
Gown and cap (some recommend shoe covers, such as disposable booties)
Prepare marked bags for proper disposal/removal of clothing and equipment.
The precautions against infection listed immediately above should be taken by all clinicians
directly involved in any pediatric intubation or airway management. Asymptomatic infection in
children is common and poses a risk for disease transmission.
Avoid pretreatment with nebulizers if possible; use MDI instead.
Preoxygenation Preoxygenate patient for 3 to 5 minutes with 100% O 2 using low or moderate flow rates (10 to
15 L/minute) and NRB mask. Avoid BMV if at all possible. 5 minutes of preoxygenation
preferred if circumstances permit.
If needed, can preoxygenate with modified NIV by using tightly fitting, non-vented mask
connected to closed-circuit, dual-limb ventilator with HEPA filter. Use a full-face mask if
available (reduces aerosolization). Mask must fit standard ventilator tubing. Continue NIV until
patient apneic. Suspend ventilator before removing mask for intubation.
If patient remains hypoxic (SpO 2 <93%) using NRB mask and NIV with closed circuit not
available, can use BMV with HEPA filter and PEEP valve. Hold mask tightly on patient's face
using 2-hand thenar technique, increase oxygen flow rate as needed, and have patient breathe
passively. Perform synchronized bag-assist ventilation only if required.
Avoid high-flow oxygenation methods (eg, flush rate) unless clinically required.
Avoid nasal cannula for oxygenation, including apneic oxygenation.
Upright posture or reverse Trendelenburg positioning improves preoxygenation.
Avoid BMV if at all possible; use HEPA filter if BMV must be performed.
If BMV necessary, 2-person thenar technique gives better seal and reduces
aerosolization/contamination risk (provided entry of additional provider can be avoided).
Provide BMV using low volumes and relatively high rates.
Pre-intubation May give IV fluid bolus prior to giving RSI medications to patients who are volume depleted.
optimization
Avoid high-volume fluid resuscitation in COVID-19 patients at risk for ARDS.
Push-dose pressor may be needed for patients at high risk for hemodynamic decompensation
(options include phenylephrine 100 micrograms IV or epinephrine 10 micrograms IV).*
Vasopressor (eg, norepinephrine) infusion may be needed for patients with hypotension or
hemodynamic instability before or following administration of RSI medications.
Paralysis with Use high-dose NMBA: rocuronium 1.5 mg/kg IV or succinylcholine 2 mg/kg IV. Goal is rapid-
induction onset apnea and elimination of cough.
Protection of patient Refer to "Preparation" above and "Post-intubation management" below.

and staff
Placement (intubation) Use video laryngoscopy whenever possible.
Performed by experienced intubator.
Supraglottic airway preferred for rescue oxygenation and ventilation if needed (eg, intubation
difficulty).
Ensure ETT is inserted 19 to 22 cm (measured at teeth); may reduce need for confirmation
by chest radiograph.
Post-intubation Inflate cuff immediately following ETT placement and prior to initiating PPV.
management
Confirm placement of the ETT. If a colorimeter or other removable EtCO 2 detector is used,
clamp the ETT before removing the device.
After confirming ETT placement, clamp the ETT, connect the ventilator tubing, and then remove
the clamp. HEPA filter between ETT and ventilator should be in place. Start mechanical
ventilation. Secure the ETT.
Ventilator settings suitable for patient with ARDS are likely to be needed (assuming COVID-19-
related respiratory illness is reason for intubation). ¶
Procedure bundles can reduce exposure. May choose to perform intubation and central venous
catheter placement together and then obtain portable chest radiograph to assess both.
Limit ventilator disconnections. When disconnection required, clamp ETT first and disconnect at
end-expiration.
Ideally, use ETT and ventilator with in-line adaptors for suctioning and bronchoscopy.
Ensure adequate sedation for patient care and safety and to avoid accidental extubation or
disconnection of tubing.
Bag, transport, and clean all equipment as required.
Use proper PPE doffing, supervised by coach or other team member. Once PPE is removed,
thoroughly clean your hands and any exposed skin on the neck and face.
OR: operating room; RSI: rapid sequence intubation; NMBA: neuromuscular blocking agent (paralytic medication); IVF: intravenous
fluid; HEPA: high-efficiency particulate air; ETT: endotracheal tube; PPE: personal protective equipment; PAPR: powered air-purifying
respirator; MDI: metered dose inhaler; O 2 : oxygen; NRB: nonrebreather; BMV: bag-mask ventilation; NIV: noninvasive ventilation;
SpO 2 : oxygen saturation; PEEP: positive end-expiratory pressure; IV: intravenous; ARDS: acute respiratory distress syndrome; PPV:
positive-pressure ventilation; EtCO 2 : end-tidal carbon dioxide; SBP: systolic blood pressure; FiO 2 : fraction of inspired oxygen.
* The use of a push-dose pressor is based on clinical judgement. It is most appropriate for patients with overt shock (eg, SBP <90
mmHg, SI >1) but may be useful in any hemodynamically unstable patient being intubated. For adults, options include phenylephrine
100 micrograms (50 to 200 micrograms) IV or epinephrine 10 micrograms (5 to 20 micrograms) IV, depending upon whether
vasoconstriction alone or vasoconstriction and inotropic support is desired. Appropriate measures to improve hemodynamics as much as
possible should be taken prior to intubation and push-dose pressor use.
¶ Initial ventilator management for adults with ARDS includes low tidal volume (6 mL/kg predicted body weight), volume-limited assist
control mode, PEEP (10 to 15 cm H 2 O), and high FiO 2 (1.0). These settings are modified based on patient response. Refer to UpToDate
topics discussing ventilator management in ARDS for details. For initial settings in children, please refer to UpToDate topics on initiating
mechanical ventilation in children.
References:
1. Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-
nCoV) patients. Can J Anaesth 2020.
2. Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines
from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care
Medicine and the Royal College of Anaesthetists. Anaesthesia 2020.
3. Mason J, Herbert M. Novel Coronavirus 2019 (COVID-19). Available at:
www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?
MainSearch=%22covid%22&SearchType=%22text%22 (Accessed on March 28, 2020).
4. Weingart S. COVID Airway Management Thoughts. Available at: https://emcrit.org/emcrit/covid-airway-management/ (Accessed
on March 28, 2020).
Coronavirus disease 2019 (COVID-19) emergency intubation checklist
This graphic shows one example of an emergency intubation checklist for patients with suspected or confirmed coronavirus
disease 2019 (COVID-19).
ECG: electrocardiogram; BP: blood pressure; FiO 2 : fraction of inspired oxygen; RSI: rapid sequence intubation; C/I: contraindication;
CICO: can't intubate can't oxygenate; EtCO 2 : end-tidal carbon dioxide; O 2 : oxygen; NPA: nasopharyngeal airway.
Reproduced with permission. Copyright © 2020 Safe Airway Society of Australia and New Zealand. The COVID-19 Emergency
Intubation Checklist and other COVID-19-related resources are available at https://www.safeairwaysociety.org/covid19/.
Putting on personal protective equipment
Sequence for putting on personal protective equipment.
Reproduced from: Centers for Disease Control and Prevention. Protecting Healthcare Personnel: Sequence for
Donning and Removing Personal Protective Equipment. Available at:
https://www.cdc.gov/hai/prevent/ppe.html (Accessed on March 20, 2020).
Taking off personal protective equipment
Reproduced from: Centers for Disease Control and Prevention. Protecting Healthcare Personnel: Sequence for Donning and Removing
Personal Protective Equipment. Available at: https://www.cdc.gov/hai/prevent/ppe.html (Accessed on March 20, 2020).
Example of N95 mask
Reproduced from: N95 Respirators and Surgical Masks (Face Masks). U.S. Food & Drug Administration. Available at:
https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-and-surgical-
masks-face-masks (Accessed on March 21, 2020).
Endotracheal intubation while wearing powered air-purifying

respirators
Two anesthesiologists using a videolaryngoscope for endotracheal intubation while wearing

powered air-purifying respirators.
From: Hong-Fei Z, Lu-Long B, Lin Y, et al. Response of Chinese anesthesiologists to the COVID-19
outbreak. Anesthesiology 2020. DOI: 10.1097/ALN.0000000000003300. Copyright © 2020 the American
Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized
reproduction of this material is prohibited.
Powered air-purifying respirator
Reproduced from: Respirator Fact Sheet. US Centers for Disease Control and
Prevention. Available at:
https://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respsars.html
(Accessed on April 8, 2020).
Predicted body weight and tidal volume for men
Height PBW Tidal volume
Feet/inches Inches Centimeters kg 4 mL/kg 5 mL/kg 6 mL/kg 7 mL/kg 8 mL/kg
4' 0" 48 122 22.4 90 112 134 157 179
4' 1" 49 124 24.7 99 124 148 173 198
4' 2" 50 127 27 108 135 162 189 216
4' 3" 51 130 29.3 117 147 176 205 234
4' 4" 52 132 31.6 126 158 190 221 253
4' 5" 53 135 33.9 136 170 203 237 271
4' 6" 54 137 36.2 145 181 217 253 290
4' 7" 55 140 38.5 154 193 231 270 308
4' 8" 56 142 40.8 163 204 245 286 326
4' 9" 57 145 43.1 172 216 259 302 345
4' 10" 58 147 45.4 182 227 272 318 363
4' 11" 59 150 47.7 191 239 286 334 382
5' 0" 60 152 50 200 250 300 350 400
5' 1" 61 155 52.3 209 262 314 366 418
5' 2" 62 157 54.6 218 273 328 382 437
5' 3" 63 160 56.9 228 285 341 398 455
5' 4" 64 163 59.2 237 296 355 414 474
5' 5" 65 165 61.5 246 308 369 431 492
5' 6" 66 168 63.8 255 319 383 447 510
5' 7" 67 170 66.1 264 331 397 463 529
5' 8" 68 173 68.4 274 342 410 479 547
5' 9" 69 175 70.7 283 354 424 495 566
5' 10" 70 178 73 292 365 438 511 584
5' 11" 71 180 75.3 301 377 452 527 602
6' 0" 72 183 77.6 310 388 466 543 621
6' 1" 73 185 79.9 320 400 479 559 639
6' 2" 74 188 82.2 329 411 493 575 658
6' 3" 75 190 84.5 338 423 507 592 676
6' 4" 76 193 86.8 347 434 521 608 694
6' 5" 77 196 89.1 356 446 535 624 713
6' 6" 78 198 91.4 366 457 548 640 731
6' 7" 79 201 93.7 375 469 562 656 750
6' 8" 80 203 96 384 480 576 672 768
6' 9" 81 206 98.3 393 492 590 688 786
6' 10" 82 208 100.6 402 503 604 704 805
6' 11" 83 211 102.9 412 515 617 720 823
7' 0" 84 213 105.2 421 526 631 736 842
PBW: predicted body weight.
Reproduced from: NHLBI ARDS Network. Available at: http://www.ardsnet.org/ (Accessed on November 20, 2012).
Predicted body weight and tidal volume for women
Height PBW Tidal volume
Feet/inches Inches Centimeters kg 4 mL/kg 5 mL/kg 6 mL/kg 7 mL/kg 8 mL/kg
4' 0" 48 122 17.9 72 90 107 125 143
4' 1" 49 124 20.2 81 101 121 141 162
4' 2" 50 127 22.5 90 113 135 158 180
4' 3" 51 130 24.8 99 124 149 174 198
4' 4" 52 132 27.1 108 136 163 190 217
4' 5" 53 135 29.4 118 147 176 206 235
4' 6" 54 137 31.7 127 159 190 222 254
4' 7" 55 140 34 136 170 204 238 272
4' 8" 56 142 36.3 145 182 218 254 290
4' 9" 57 145 38.6 154 193 232 270 309
4' 10" 58 147 40.9 164 205 245 286 327
4' 11" 59 150 43.2 173 216 259 302 346
5' 0" 60 152 45.5 182 228 273 319 364
5' 1" 61 155 47.8 191 239 287 335 382
5' 2" 62 157 50.1 200 251 301 351 401
5' 3" 63 160 52.4 210 262 314 367 419
5' 4" 64 163 54.7 219 274 328 383 438
5' 5" 65 165 57 228 285 342 399 456
5' 6" 66 168 59.3 237 297 356 415 474
5' 7" 67 170 61.6 246 308 370 431 493
5' 8" 68 173 63.9 256 320 383 447 511
5' 9" 69 175 66.2 265 331 397 463 530
5' 10" 70 178 68.5 274 343 411 480 548
5' 11" 71 180 70.8 283 354 425 496 566
6' 0" 72 183 73.1 292 366 439 512 585
6' 1" 73 185 75.4 302 377 452 528 603
6' 2" 74 188 77.7 311 389 466 544 622
6' 3" 75 190 80 320 400 480 560 640
6' 4" 76 193 82.3 329 412 494 576 658
6' 5" 77 196 84.6 338 423 508 592 677
6' 6" 78 198 86.9 348 435 521 608 695
6' 7" 79 201 89.2 357 446 535 624 714
6' 8" 80 203 91.5 366 458 549 641 732
6' 9" 81 206 93.8 375 469 563 657 750
6' 10" 82 208 96.1 384 481 577 673 769
6' 11" 83 211 98.4 394 492 590 689 787
7' 0" 84 213 100.7 403 504 604 705 806
PBW: predicted body weight.
Reproduced from: NHLBI ARDS Network. Available at: http://www.ardsnet.org/ (Accessed on November 20, 2012).
Low tidal volume ventilation in patients with acute respiratory distress syndrome
Initial ventilator settings

Calculate predicted body weight (PBW)
Male = 50 + 2.3 [height (inches) - 60] OR
50 + 0.91 [height (cm) - 152.4]
Female = 45.5 + 2.3 [height (inches) - 60] OR
45.5 + 0.91 [height (cm) - 152.4]
Set mode to volume assist-control

Set initial tidal volume to 6 mL/kg PBW
Set initial ventilator rate ≤35 breaths/min to match baseline minute ventilation
Subsequent tidal volume adjustment

Plateau pressure goal: Pplat ≤30 cm H 2 O
Check inspiratory plateau pressure with 0.5 second inspiratory pause at least every four hours and after each change in PEEP or
tidal volume.
If Pplat >30 cm H 2 O, decrease tidal volume in 1 mL/kg PBW steps to 5 or if necessary to 4 mL/kg PBW.
If Pplat <25 cm H 2 O and tidal volume <6 mL/kg, increase tidal volume by 1 mL/kg PBW until Pplat >25 cm H 2 O or tidal volume = 6 mL/kg.
If breath stacking (autoPEEP) or severe dyspnea occurs, tidal volume may be increased to 7 or 8 mL/kg PBW if Pplat remains ≤30 cm H 2 O.
Arterial oxygenation and PEEP

Oxygenation goal: PaO 2 55 to 80 mmHg or SpO 2 88 to 95 percent
Use these FiO 2 /PEEP combinations to achieve oxygenation goal:
FiO 2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 5 5 to 8 8 to 10 10 10 to 14 14 14 to 18 18 to 24
PEEP should be applied starting with the minimum value for a given FiO 2 .
Pplat: plateau pressure; PaO 2 : arterial oxygen tension; SpO 2 : oxyhemoglobin saturation; PEEP: positive end-expiratory
pressure; FiO2: fraction of inspired oxygen.
Adapted from: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute
respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.
Double-triggering
Tracings of airway pressure (Paw), flow, and volume in a sedated patient undergoing assist-control
mechanical ventilation, depicting classic and frequent dyssynchrony of double cycling. Despite a set rate
of 20/minute, the actual rate is 40/minute. Diaphragmatic electrical activity signal (EaDi), superimposed
on the Paw curve, provides the mechanism, called reverse triggering. Diaphragmatic contractions are
triggered by the mechanical insufflations on a 1:1 basis and explain the second cycle.
Patient-trig: patient-triggered occurring after each mandatory breath; Time-trig: time-triggered.
Reproduced from: Pham T, Brochard LJ, Slutsky AS. Mechanical Ventilation: State of the Art. Mayo Clin Proc
2017; 92:1382. Illustration used with the permission of Elsevier Inc. All rights reserved.
Prone position: Contraindications and complications
Contraindications Complications
Shock (eg, persistent mean aterial pressure <65 mmHg) Nerve compression (eg, brachial plexus injury)
Acute bleeding (eg, hemorrhagic shock, massive Crush injury

hemoptysis)
Venous stasis (eg, facial edema)
Multiple fractures or trauma (eg, unstable fractures of
Dislodging endotracheal tube
femur, pelvis, face)
Diaphragm limitation
Spinal instability
Pressure sores (eg, facial)
Pregnancy
Dislodging vascular catheters or drainage tubes
Raised intracranial pressure >30 mmHg or cerebral
perfusion pressure <60 mmHg Retinal damage
Tracheal surgery or sternotomy within two weeks Transient reduction in arterial oxygen saturation
Vomiting
Relative contraindictions
Transient arrhythmias
Recent DVT treated for <2 days*
Anterior chest tube(s) with air leaks*
Major abdominal surgery
Recent pacemaker*
Clinical conditions limiting life expectancy* (eg, oxygen or

ventilator-dependent respiratory failure)
Severe burns*
Lung transplant recipient*
Prior use of rescue therapies* ¶
DVT: deep vein thrombosis.

* Based upon exclusion criteria from the Prone Postioning in Severe ARDS trial (PROSEVA).
¶ Patients in whom benefit is not assured include: patients on inhaled nitric oxide, on almitrine bimesyalte, extracorporeal membrane
oxygeneation (ECMO), or noninvasive ventilation (NIV) prior to intubation.
Data from:
1. Ryan DW, Pelosi P. The prone position in acute respiratory distress syndrome. BMJ 1996; 312:860.
2. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;
368:2159.
Procedure for prone positioning
Preparation
1. Check for contraindications.
a. Facial or pelvic fractures
b. Burns or open wounds on the ventral body surface
c. Conditions associated with spinal instability (eg, rheumatoid arthritis, trauma)
d. Conditions associated with increased intracranial pressure
e. Life-threatening arrhythmias
2. Consider possible adverse effects of prone positioning on chest tube drainage.
3. Whenever possible, explain the maneuver to the patient and/or their family.
4. Confirm from a recent chest roentgenogram that the tip of the endotracheal tube is located 2 to 4 cm above the main carina.
5. Inspect and confirm that the endotracheal tube and all central and large bore peripheral catheters are firmly secured.
6. Consider exactly how the patient's head, neck, and shoulder girdle will be supported after they are turned prone.
7. Stop tube feeding, check for residual, fully evacuate the stomach, and cap or clamp the feeding and gastric tubes.
8. Prepare endotracheal suctioning equipment, and review what the process will be if copious airway secretions abruptly interfere
with ventilation.
9. Decide whether the turn will be rightward or leftward.
10. Prepare all intravenous tubing and other catheters and tubing for connection when the patient is prone.
a. Assure sufficient tubing length
b. Relocate all drainage bags on the opposite side of the bed
c. Move chest tube drains between the legs
d. Reposition intravenous tubing toward the patient's head, on the opposite side of the bed
Turning procedure
1. Place one (or more) people on both sides of the bed (to be responsible for the turning processes) and another at the head of
the bed (to assure the central lines and the endotracheal tube do not become dislodged or kinked).
2. Increase the FiO 2 to 1 and note the mode of ventilation, the tidal volume, the minute ventilation, and the peak and plateau
airway pressures.
3. Pull the patient to the edge of the bed furthest from whichever lateral decubitus position will be used while turning.
4. Place a new draw sheet on the side of the bed that the patient will face when in this lateral decubitus position. Leave most of
the sheet hanging.
5. Turn the patient to the lateral decubitus position with the dependent arm tucked slightly under the thorax. As the turning
progresses the nondependent arm can be raised in a cocked position over the patient's head. Alternatively, the turn can progress
using a log-rolling procedure.
6. Remove ECG leads and patches. Suction the airway, mouth, and nasal passages if necessary.
7. Continue turning to the prone position.
8. Reposition in the center of the bed using the new draw sheet.
9. If the patient is on a standard hospital bed, turn his/her face toward the ventilator. Assure that the airway is not kinked and
has not migrated during the turning process. Suction the airway if necessary.
10. Support the face and shoulders appropriately avoiding any contact of the supporting padding with the orbits or the eyes.
11. Position the arms for patient comfort. If the patient cannot communicate, avoid any type of arm extension that might result in
a brachial plexus injury.
12. Auscultate the chest to check for right mainstem intubation. Reassess the tidal volume and minute ventilation.
13. Adjust all tubing and reassess connections and function.
14. Reattach ECG patches and leads to the back.
15. Tilt the patient into reverse Trendelenburg. Slight, intermittent lateral repositioning (20 to 30°) should also be used, changing
sides at least every two hours.
16. Document a thorough skin assessment every shift, specifically inspecting weight bearing, ventral surfaces.
FiO 2 : fraction of inspired oxygen.
Reproduced with permission from: Messerole E, Peine P, Wittkopp W, et al. The pragmatics of prone positioning. Am J Respir Crit Care
Med 2002; 165:1359. Official Journal of the American Thoracic Society © American Thoracic Society.
Titration of PEEP
Higher PEEP/lower FiO 2
Step: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
FiO 2 0.3 0.4 0.4 0.4 0.4 0.4 0.4 0.5 0.5 0.5 0.6 0.7 0.8 0.8 0.9 1.0 1.0
PEEP 5 5 8 10 12 14 16 16 18 20 20 20 20 22 22 22 24
PEEP: positive end-expiratory pressure; FiO 2 : fraction of inspired oxygen.
Adapted from:
1. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute
respiratory distress syndrome. NEJM 2004; 351:327.
2. Meade MO, Cook DJ, Guyatt GH. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-
expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008;
299:637.
Ventilator circuits
(A) In this configuration, the leak port is always open to atmosphere. Pressure is generated as the
result of flow in the circuit and resistance through the leak port. Thus, with higher pressure, the
ventilator must deliver more flow into the circuit. It is important to appreciate that, with this design,
leak is integral to the function of the device. Thus, the leak should not be occluded. This circuit type is
commonly used in ventilators designed for noninvasive ventilation. It is also the typical design for
positive airway pressure devices used for the treatment of obstructive sleep apnea. (B) Single limb
circuit with active exhalation valve near the patient. This circuit type is typically used with portable
ventilators, such as those used for transport or in the home. During inspiration, the exhalation valve
is closed via the pressurization line from the ventilator. (C) Dual limb ventilator circuit commonly used
with critical care ventilators. In this design, the valves are within the ventilator.
Modified from: Humidification and the ventilator circuit. In: Essentials of Mechanical Ventilation, 3rd ed, Hess
DR, Kacmarek RM (Eds), McGraw-Hill Education, New York 2014.
Heat and humidification of ventilator gases
This figure demonstrates the principle of heat and humidification where inspired gas is warmed and
humidified (A) via a heat moisture exchanger (B) and expired gas cooled and dehumidified.
RH: relative humidity.
Modified from: Humidification and the Ventilator Circuit. In: Essentials of Mechanical Ventilation, 3rd ed,
Hess DR, Kacmarek RM (Eds), McGraw-Hill Education, 2014.
Richmond Agitation-Sedation Scale (RASS)
Score Term Description
+4 Combative Overtly combative or violent, immediate danger to staff
+3 Very agitated Pulls on or removes tubes or catheters, aggressive behavior toward staff
+2 Agitated Frequent nonpurposeful movement or patient-ventilator dyssynchrony
+1 Restless Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy Not fully alert, sustained (>10 seconds) awakening, eye contact to voice
-2 Light sedation Briefly (<10 seconds) awakens with eye contact to voice
-3 Moderate sedation Any movement (but no eye contact) to voice
-4 Deep sedation No response to voice, any movement to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Procedure
1. Observe patient. Is patient alert and calm (score 0)?
2. Does patient have behavior that is consistent with restlessness or agitation?
Assign score +1 to +4 using the criteria listed above.
3. If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at
speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score -1).
Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2).
Patient has any movement in response to voice, excluding eye contact (score -3).
4. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there
is no response.
Patient has any movement to physical stimulation (score -4).
Patient has no response to voice or physical stimulation (score -5).
Reproduced with permission from: Sessler C, Gosnell M, Grap MJ, et al. The Richmond agitation-sedation scale. Validity and reliability in
adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338. Copyright © 2002 American Thoracic Society.
CALMER and SHARE: Components of palliative care discussions with COVID-19 patients
CALMER: A talking map for COVID-related SHARE: A talking map for explaining resource
proactive planning allocation
Check in Show the guideline
Take a deep breath (yourself!) "Here's what our institution/system/region is doing for
patients with this condition." (Start the part directly
"How are you doing with all this?" (Take their emotional
relevant to that person.)
temperature.)
Headline what it means for the patient's care
Ask about COVID
"So for you, what this means is that we care for you on
"What have you been thinking about COVID and your
the floor and do everything we can to help you feel
situation?" (Just listen.)
better and fight this illness. What we won't do is transfer
Lay out issues you to the ICU or do CPR if your heart stops." (Note that
you talk about what you will do first, then what you
"Here is something I want us to be prepared for."/"You
won't do.)
mentioned COVID. I agree."
"Is there anything you want us to know if you have Affirm the care you will provide
COVID/if your COVID gets really bad?" "We will be doing [the care plan], and we hope you will
recover."
Motivate them to choose a proxy and talk about what
matters Respond to emotion
"If things took a turn for the worse, what you say now "I can see that you are concerned."
can help your family/loved ones."
Emphasize that the same rules apply to everyone
"Who is your backup person – who helps us make
"We are using the same rules with every other patient in
decisions if you can't speak? Who else?" (Having 2
this hospital/system/institution. We are not singling you
backup people is best.)
out."
"We're in an extraordinary situation. Given that, what
matters to you? About any part of your life? About your
health care?"
Make a recommendation – if they would be able to hear

it
"Based on what I've heard, I'd recommend [this]. What

do you think?"
Expect emotion
Watch for this – acknowledge at any point
"This can be hard to think about."
Record the discussion
Any documentation – even brief – will help your

colleagues and your patient
"I'll write what you said in the chart. It's really helpful,
thank you."
COVID: COVID-19 (coronavirus disease 2019); ICU: intensive care unit; CPR: cardiopulmonary resuscitation.
Reproduced with permission from: COVID Ready Communication Playbook. Copyright © 2020 VitalTalk. Available at:
https://www.vitaltalk.org/guides/covid-19-communication-skills/ (Accessed on May 3, 2020).

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Coronavirus disease 2019 (COVID-19): Critical care and airway

GUIDELINES AND HOSPITAL POLICIES

CLINICAL FEATURES IN CRITICALLY ILL PATIENTS

RESPIRATORY CARE OF THE NONINTUBATED PATIENT

Deciding on a modality (noninvasive modalities or invasive ventilation) — In patients with COVID-19

Monitoring on noninvasive modalities — If HFNC or NIV is administered, vigilant monitoring of patients

Nebulized medications (spontaneously breathing patients) — Nebulizers are associated with

● It is prudent to minimize the following:

• Positive airway devices for chronic nocturnal ventilation support

● Sputum induction should be avoided

● Bronchoscopy should be avoided in spontaneously breathing patients and limited to therapeutic

THE DECISION TO INTUBATE

● Rapid progression over hours

● Intubation should be performed in an airborne infection isolation room, if possible.

VENTILATOR MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME

● Pulmonary vasodilators – Pulmonary vasodilators may improve ventilation-perfusion mismatch in

● Procedure – Tracheostomy is considered a high risk procedure for aerosolization.

• To minimize cough, neuromuscular blockade is prudent.

Decannulation is considered an aerosol-generating procedure, and provided the patient remains

Cardiopulmonary resuscitation — In the event of a cardiac arrest, cardiopulmonary resuscitation (CPR)

Significant pleural effusions and barotrauma appear to be unusual as a manifestation of COVID-19. In

Others — Other supportive measures are included here.

● Hemodynamic monitoring. (See "Pulmonary artery catheterization: Indications, contraindications, and

● Ventilator-associated pneumonia precautions. (See "Risk factors and prevention of hospital-acquired

Nebulized medication — Nebulization is considered an aerosol-generating procedure. For patients with

● Select laboratory studies (eg, worsening lymphopenia, neutrophilia, troponin leak)

END OF LIFE ISSUES

DISCHARGE, RECOVERY, AND LONG TERM CARE

SURGE CAPACITY AND SCARCE RESOURCE ALLOCATION

● Care spaces (ie, beds)

● Maximization of lives saved and/or life-years saved

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

• Rapid progression over a few hours

● Several procedures, including the collection of respiratory specimens, bronchoscopy, extubation,

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 127419 Version 70.0

Diagnostic testing Actions Explanatory notes

Nasopharyngeal swab Perform SARS-CoV-2 (COVID-19) test Oropharyngeal swab is an alternative if

Other microbiology Obtain the following:

Baseline laboratory testing Obtain the following: ¶ Neutrophilia is uncommon while

Chemistry panel including LFTs Elevated LFTs are common.

ECG Baseline at admission Medications that can prolong QTc include

Supportive care Actions Explanatory notes

Goals of care Recommend early discussion and

Vascular access Place central venous catheter

Intravenous fluids and Conservative approach. Use vasopressors

Tracheal intubation Actions Explanatory notes

Indications Signs of respiratory distress (eg, accessory

Rapid sequence intubation Performed by experienced intubator

Pharmacotherapy Actions Explanatory notes

Empiric antibiotics For suspected bacterial co-infection (eg,

Adjustments to Actions Explanatory notes

ICS For asthma, continue usual dose

Oral glucocorticoids If taking as outpatient: Adjust dosing to

ACEi/ARBs Continue if there is no other reason for

Statins Patients taking a statin at baseline should

Graphic 127595 Version 5.0

Pendant reservoir cannula

Graphic 104816 Version 1.0