Evidence-based Ventilation Strategies for COVID-19
David R Janz, MD, MSc
Associate Professor of Medicine
LSU School of Medicine New Orleans
Director, Medical Intensive Care Unit
University Medical Center New Orleans
Disclosures Related to this Lecture
I do not have relationship(s) with commercial interests related to this lecture.
Disclosures in General
I do have the following relationship(s) with commercial interests.
NAME OF COMPANY: Cytovale, Inc©
RELATIONSHIP: Consultant (sepsis biomarkers)RECEIVED: honoraria
A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Objectives
• Discuss the evidence-based approach to non-invasive and invasive ventilation of the acute respiratory failure patient
• Review the approach at UMCNO to patients with respiratory failure from COVID-19
• Discuss “Closed Circuit” Non-invasive ventilation
Evidence-based Management of COVID ARDS: A Timeline
ICU Admission
Support with HFNC-or-
NIPPV(if COPD, HF, obese,
weakness)
Intubation
ARMA6 vs 12 cc/kg PBW
Tidal volume = 6 x PBW(Men ≈ 420cc)
(Women ≈ 360cc)
High vs Low PEEP
ARDSnet High PEEP ladder
(up to 24 peep)
PROSEVAProne Positioning
Prone in first 24hrs if PaO2/FiO2 <150
(impute P/f from S/f)
16hrs prone8 hrs supine
Stop when P/f >150 in the supine position
Steroids
COPDAsthma
Chronic SteroidsRefractory Shock
FACTTConservative
Fluids
Diuresis If on little or no
pressors
ABC Trial
SAT/SBT daily
UMC Covid-19 Critical Care Guidelines – 03/25/20
VENTILATION - Avoid Nebulizers - BiPAP for COPD/CHF/OHS - HHFNC with Caution
4-6 cc/kg PBW Tidal Volume
pH < 7.2
RR to 34
Re-Check pH
Vt to ≤ 8 cc/kg PBW
pH ≥ 7.2
Ø RR or Vt Change
ARDSnet High PEEP Ladder
Wean FiO2 / PEEP Based on
SaO2 ≥ 88%
pH < 7.2
pH ≥ 7.2
SaO2 ≤ 96% +
FiO2 ≥ 55%
PRONE POSITIONING*
Requires adequate nursing resources
Prone @ 4pm Supine @
8am
Continue as Long as
SaO2 ≤ 96%
+ FiO2 ≥ 55% In Supine Position
FLUID MANAGEMENT
1. Don’t Volume Resuscitate Unless Marked Signs of Hypovolemia
2. Limit IV Med Volume
PRESSORS
Lasix Dosing: Creatinine X 40
q12
Lasix Dosing: Creatinine X 40
q24
Ø Lasix
Lo
w
REFRACTORY HYPOXEMIA
Lasix Works: I/O even/- in 24 hrs
Lasix Doesn’t Work: I/O + in 24 hrs
Continue + Aggressive K+ Replacement with 2mg of Mg2+ daily
Hemodialysis CRRT strongly discouraged due to resource
needs and filter clogging from hypertriglyceridemia; requires ICU director approval and adequate nursing resources
given 1:1 nursing needs.
SEDATION - Lovenox DVT Prophylaxis - No Insulin drip for Hyperglycemia - Trophic tube feeds unless vomiting
Prone/Desat?
LIGHT SEDATION
HEAVY SEDATION
Fentanyl (if available) Precedex
+/- Propofol
Fentanyl (if available) Precedex Propofol
+/- Versed
Daily SAT/SBT
Nimbex (do not wean) turned up until no
breathing over vent/ no movement to pain
After RASS -5
Yes
No
Once Daily Nimbex Off
Trial
LABS • ≤ 1 Daily
o CBC o BMP
• = 1 Daily ABG if o On Nimbex o Not breathing over vent o Unable to measure SaOs
*Contraindications for Prone Positioning: • S/f ratio >150 on high peep ladder (using
S/f table)
• On dialysis or ultrafiltration
• >300 pounds
• Stop proning after 4 cycles
• hemodynamic decompensation during a flip
• Never in PACU or ED
“In adults with COVID-19 and acute hypoxemic respiratory failure, if HFNC is not available and there is no urgent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short-interval assessment for worsening of respiratory failure.”
“The risk of potential transmission with NIPPV to healthcare workers is unknown.”
“ATS/CHEST recommendation:
For patients at high risk for extubation failure who have been receiving mechanical ventilation for more than 24 hours, and who have passed an SBT, we recommend extubation to preventive NIV
(strong recommendation, moderate certainty in the evidence)”
#SAT/SBT Passing Criteria
- 8 ≥ RR ≤ 35
- SaO2 ≥ 88%
- 60 ≥ HR ≤ 130
- No new arrhythmias
- No respiratory distress
- No worsening shock
- RASS > -4
Controlled Mode of Ventilation:
≤ 50% FiO2, ≤ 10 PEEP
SAT/SBT#:
- SAT: all sedation off
(okay to leave dexmedetomidine at half dose)
- SBT: pressure support 5, PEEP 5, FiO2 40%
*Bipap Contraindications
- Vomiting tube feeds in
past 24 hours
- Facial trauma/surgery
- Facial hair
- Copious secretions
- Severe hemodynamic
instability
Pressure support
-and-
PEEP until passes
SBT
Extubate to Closed Circuit
Bipap* with these settings
Fa
ils (M
od
era
te)
At least once daily
trial off Bipap
Extubate to 6 L/min nasal canula
(if COPD, HF, morbid obesity, or weakness,
extubate to Bipap)
UMCNO COVID Ventilator Liberation Guidelines 4.4.20
”Closed Circuit” Bipap
Works Cited
• Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103.
• Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253-1263. doi:10.1164/rccm.201703-0548ST.
• Devlin JW, Skrobik Y, Gélinas C, et al. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):1532-1548. doi:10.1097/CCM.0000000000003259.
• 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(18):1301-1308. doi:10.1056/NEJM200005043421801.
• Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873. doi:10.1001/jama.2010.218.
• National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-2575. doi:10.1056/NEJMoa062200.
• SCCM Surviving Sepsis Guidelines Management of COVID-19. 2020
• Schmidt GA, Girard TD, Kress JP, et al. Official Executive Summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med. October 2016:rccm.201610–2076ST. doi:10.1164/rccm.201610-2076ST.
