SPECIAL CORONAVIRUS

COVID-19: A
Quick Look
at Aspects of
Critical Care
BY BILL PRUITT, RRT, CPFT, AE-C, FAARC

As coronavirus cases surge in the

United States with estimates that 5%
of patients will need intensive care,
US hospitals may quickly consume
their limited supply of critical care
beds and equipment.

INTRODUCTION
The sudden appearance of the novel coronavirus
disease 2019 (COVID-19) in China and subsequent
rapid spread throughout the world has not been
seen before in looking back at other pandemics. The
coronavirus is easily transmitted person-to-person and
once established it can quickly carry a patient from
being healthy to being critically-ill, including acute
respiratory distress syndrome (ARDS) caused by the
viral pneumonia. Younger patients seem to be less
affected while older patients and those with comorbid
conditions are at greater risk for increased morbidity
(having the disease and poor health) and increased
mortality.1-2
COVID-19 is transmitted by respiratory droplets
(as in coughing or sneezing), by body fluids, or by
touching contaminated surfaces. Patients can be free
from symptoms and still spread the disease.3 Of the
83,000 cases of COVID-19 cases reported in China by

8 RT | FOR DECISION MAKERS IN RESPIRATORY CARE MARCH-APRIL 2020

RT20__04__08-11__CORONAVIRUS.indd 8 4/14/20 7:59 AM

 This transmission electron microscope image
shows SARS-CoV-2, the virus that causes
COVID-19, isolated from a patient in the US,
emerging from the surface of cells cultured in the
lab. Photo credit: National Institute of Allergy and
Infectious Diseases, Rocky Mountain Laboratories,
National Institutes of Health.

MARCH-APRIL 2020 RTMAGAZINE.COM 9

RT20__04__08-11__CORONAVIRUS.indd 9 4/14/20 7:59 AM

 SPECIAL CORONAVIRUS
the Chinese Center for Disease Control and Prevention (C-CDC),
81% were classified as mild (having mild or no pneumonia), 14%
were classified as severe (having dyspnea, tachypnea >30 BPM,
SpO2 <93%, PaO2/FiO2 <300, and/or lung infiltrates within 24
to 48 hours), and 5% were classified as critical (having respiratory
failure, septic shock, and/or multiple organ dysfunction or
failure).1 From the C-CDC report published in February 2020,
death occurred in 2.3% of the confirmed cases of COVID-19, all
occurring in the critically-ill classification (no deaths occurred in
the mild or severe population).1
ICU admission may occur after a gradual decline in health as the
median duration from onset of symptoms to going into the ICU
is 9 to 10 days and once admitted, ARDS has been diagnosed in
two-thirds of the ICU admissions. 2 According to the CDC, most
patients confirmed to have COVID-19 have fever and/or cough
and difficulty breathing.4 Healthcare personnel (HCP) should
take aggressive measures to protect themselves from exposure to
COVID-19, protect transmitting the disease to other patients,
and protect against carrying the virus into the community.
INFECTION CONTROL MEASURES
CDC recommendations for infection control are clear on the
need for proper hand hygiene and use of personal protective
equipment (PPE) related to COVID-19. Infection control
procedures, if properly followed, protect HCPs, other patients,
the community, and protect against contaminating surfaces that
could later transmit the virus. Proper hand hygiene is the first,
easiest, and most important measure to take in infection control.
Hand hygiene includes thorough washing with soap and water
for at least 20 seconds before and after patient contact and before
and after use of PPE (or use of alcohol-based hand rub containing
60-90% alcohol).
The CDC recommendations state that
an N95 respirator masks is needed anytime
a procedure is done that would produce
an aerosol (ie sputum induction or open-
system suctioning) to provide filtered
inspired air. N95 masks need to be fit-
tested to ensure proper protection. For
those with facial hair or other issues that
may interfere with using the N95 masks,
powered air purifying respirators should be worn.
Eye protection (including goggles or disposable face shield)
should be worn to protect against splashes and sprays (eyeglasses
and contact lenses are not adequate for protection). In times of
limited supply, N95 masks and eye protection devices may have
to be worn from patient to patient (extended use). Use of clean
isolation gowns and clean gloves are recommended and should be
replaced between patients.
Patients should be in a single-person room with the door closed
10 RT | FOR DECISION MAKERS IN RESPIRATORY CARE MARCH-APRIL 2020
RT20__04__08-11__CORONAVIRUS.indd 10
and airborne infection isolation rooms (negative pressure rooms)
should be reserved for patients having procedures done which
generate aerosols. The CDC infection control recommendations
also address issues for limited supply of PPE, proper training for
donning and removing PPE, alternatives for N95 respirators if
supplies are lacking, and policies addressing patient transport,
visitors, cleaning, use and storage of equipment, and more.5
CRITICAL CARE FOR COVID-19 PATIENTS
As mentioned earlier, 5% of COVID-19 patients will need
intensive care. ICU admissions tend to be older (median age of 60
years) and some 40% have comorbid conditions including cardiac
disease and diabetes. With viral pneumonia and acute hypoxemic
respiratory failure, the management of ICU patients with
COVID-19 matches the current approach for ARDS, with a few
exceptions. Some patients may be successfully managed with the
use of high-flow nasal oxygen therapy or noninvasive ventilation;
however, there needs to be an awareness of generating an aerosol
from the high-flow approach or if the noninvasive masks have
leaks that release air into the environment. If either or both of
these options are tried but unsuccessful, patient management
needs to move to early intubation and initiation of mechanical
ventilation.
Lung-protective strategies are the best approach in dealing
with COVID-19 patients with consideration for using the
proper tidal volume, PEEP levels linking to FiO 2 settings,
limitation of inspiratory pressures, prone positioning, and
possible use of extracorporeal membrane oxygenation (ECMO)
if conditions warrant. A minimum distance of six feet should be
used to separate patients if single patient private rooms are not
available. Intravenous fluids should be managed conservatively
and empiric early administration of antibiotics should be used to
address possible bacterial
The ICU surge can overwhelm a pneumonia.
hospital, a city, a region, and even Strict infection control
a nation, so proper planning must measures are needed as
happen immediately to look for discussed above. Many
ways to reduce the potential crush critically ill patients with
of critically-ill patients... COVID-19 develop shock
—Bill Pruitt RRT, CPFT, AE-C, FAARC
and acute kidney failure;
kidney dialysis may need
to be provided in addition to the other supportive measures
mentioned.2
Patients may need to have measures in place to evaluate and
treat delirium, and counseling regarding death and dying may
need consideration. Nutritional support should be provided
to support the immune system and reduce stress on the body.
With the virus beginning in China, Chinese herbs were used in
treatment and there may be research coming out in the future that
investigates this aspect of care.
4/14/20 7:59 AM
 CORONAVIRUS SPECIAL

The Cochrane Library has prepared a Special Collection of

reviews that evaluate the safety and effectiveness of many of the
management issues just mentioned. Using an up-to-date evidence-
based approach should help bring about more positive outcomes
when dealing with critically ill COVID-19 patients. The special
collection on COVID-19 can be found online at Cochrane
COVID-19 FATALITIES SHARED THESE
CLINICAL CHARACTERISTICS
Researchers studying a cohort of 85 COVID-19 fatalities
in Wuhan, China found most patients who died were male,

Library. Patients should be asked about enrolling in clinical trials
for researching supportive or targeted therapies.
As the disease spreads rapidly, planning early on is needed at
both local and regional levels to handle a surge in critical care
resources such as trained and experienced staff, equipment—
particularly ventilators, ICU beds, PPE supplies, ECMO, and
dialysis machines. 2 The ICU surge can overwhelm a hospital, a
city, a region, and even a nation, so proper planning must happen
immediately to look for ways to reduce the potential crush
of critically-ill patients and deal with the high acuity of large
numbers.
Finally, planning needs to be done to handle the possibility
of triaging patients in the face of a shortage of ventilators. A
proposal published in Chest in 2019 examined this dilemma and
gave a reasoned approach on how this might be done.6 Patients
are prioritized based on prognosis for short-term survival (using
SOFA for adults/PELOD-2 for pediatrics), prognosis for long-
term survival (using assessment of comorbid conditions), with
secondary considerations including life-related (life-cycle) status.
This gives higher priority to children up to age 49, then 50-69,
70-84, >85 years of age, and pregnancy. If priority scores are
equal, priority moves to some fair, transparent chance of getting
mechanical ventilation. This could be first-come, first-served, or
over age 50, with comorbidities such as hypertension,
diabetes, coronary heart disease, and low blood
eosinophil counts. Notably, researchers observed these
patients averaged less than a week between admission
and death (avg 6.35 days).
Some of the clinical characteristics of the patient
fatalities included: a 65.8 median age; 72.9 % were men;
Most common symptoms were fever, dyspnea, and fatigue;
Most common comorbidities were hypertension, diabetes,
and coronary heart disease; 80%+ of patients had very low
counts of eosinophils on admission; and complications
included respiratory failure, shock, ARDS and cardiac
arrhythmia.
Based on their findings, eosinophilopenia (abnormally
low levels of eosinophils in the blood) may indicate a poor
prognosis. RT
%1/(146%17)*++ - -
㔹5GETGVKQP%NGCTCPEG

a lottery. 6 㔹2WNOQPCT[4GJCDKNKVCVKQP
㔹'PJCPEKPI
CONCLUSION 5GETGVKQP/QDKNK\CVKQP

We are in the middle of an explosion of COVID-19 patients

needing intensive care. This pandemic is widespread and moving HFCWO �,ŝŐŚ&ƌĞƋƵĞŶĐLJŚĞƐƚtĂůůKƐĐŝůůĂƟŽŶ�
rapidly. Hospitals and healthcare providers will be challenged in with Vest with Cuirass
a multitude of issues to meet the need of these patients. Early,
appropriate, extensive measures can help blunt the impact of the
COVID-19 pandemic and help us prepare for the next. RT

Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a senior
instructor and director of clinical education in the department of
Cardiorespiratory Sciences, College of Allied Health Sciences, at
the University of South Alabama in Mobile. Bill also spends time Coming Soon!
helping uninsured adult patients who have pulmonary or sleep issues HFT - High Flow Therapy -
at Victory Health Partners, a faith-based clinic in Mobile that serves
8SFRPLQJ([KLELWLRQ
the Gulf coast region. Contact editor@RTmagazine.com. WK-XQH
0LDPL%HDFK)ORULGD

REFERENCES .RUHDQ3DYLOOLRQ
*References (#1-6) available at https://www.rtmagazine.com/
disorders-diseases/critical-care/icu-ventilation/covid-19-aspects-
of-critical-care/
magenta
cyan
yellow
black SEOIL_2003_PG11_QPV_1-1.pgs 04.14.2020 06:02 ADVANSTAR_PDF/X-1a

MARCH-APRIL 2020 RTMAGAZINE.COM 11

RT20__04__08-11__CORONAVIRUS.indd 11 4/14/20 7:59 AM

Copyright of RT: The Journal for Respiratory Care Practitioners is the property of MEDQOR
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.