BERNADETT KOVACS MD FRCPC

Assistant Professor NOSM

Clinician Lecturer UOttawa
Berlin, D.A., Gulick, R.M and Martinez, F.J.Severe Covid 19. N Engl J Med

2020;3 83: 2451-60

 Covid 19 pneumonia is ARDS

• Gattinoni, L. et al., Intensive Care Med 2020, 46:1099-1102 - error in slide high lung compliance should be high lung
elastane and thus low compliance

• Not new phenomenon. Calfee CS et al., Lancet Respir Med 2014, 2: 611-620

• Phenotype 1 vs Phenotype 2 - hyper-inflamatory with higher PEEP showing benefit vs hypo-

inflamatory with higher PEEP showing detrimental effects
From: Care for Critically Ill Patients With COVID-19

JAMA. 2020;323(15):1499-1500. doi:10.1001/jama.2020.3633

Figure Legend:

Summary of Caring for Critically Ill Patients With COVID-19

Copyright 2020 American Medical Association. All

Date of download: 5/28/2021
Rights Reserved.
Berlin, D.A., Gulick, R.M and Martinez,

F.J.Severe Covid 19. N Engl J Med 2020;3 83:

2451-60
 Post Intubation

onsiderations
EEP 10, VT 6 ml/kg/PBW
ure Pplat, compliance and driving pressure (ΔP=Pplat-PEEP)
14., Pplat < 30 permit hypercarbia.

heterogeneity of cases especially early in disease presentation

mal compliance with moderate to severe hypoxemia
ung compliance > 40 or ΔP <14 consider liberalizing to VT of 8ml/kg/PBW if this allows l
 Post Intubation

• PEEP titrate to physiology & lung mechanics, higher PEEP in obese patients
• If normal (>40) compliance
• higher PEEP settings may improve oxygenation but ΔP may increase, CO may decrease
• Consider
• High PEEP titration tables
• R/I ratio

Assess for recruitability and/or response to PEEP

Decremental PEEP titration
1. Measuring AOP and R/I - over .5 high recruitbality lung recruitment manoeuvre with
2. Test response at 2 levels of PEEP with ABG, positive airway pressure
driving pressure & hemodynamics
Start titration from 20PEEP by 2 each 2
1. Compares what is is being exhaled + predicted to be lost minutes & monitor S(pO2)
by dropping PEEP & compare to total volume exhaled - If s(pO2) drops below 90, optimal PEEP
predicted
Compliance of recruited lung is compared to compliance is step before saturation drop
of lung at low PEEP
Curtesy of University of Toronto Interdepartmental Division of Critical Care
 Post Intubation

• Sedation should be tailored to patient and mechanical ventilation requirements.

• RASS - 5 is not always the goal

• Routine paralysis is not recommended BUT may be required

• Stop paralysis daily where possible and restarting only if necessary

• Local strategies are recommended for conservation & substitution

• bolus as well as infusion of paralytics

 Post Intubation

• Prone position - improves oxygenation & lung mechanics

• Good compliance P/F <100 after optimization of PEEP and sedation.
• Poor compliance as per ARDS guidelines (P/F <150) after optimization of PEEP & sedation.
• Optimal PEEP should be reassessed
• Does not always require paralysis.
• Consider stopping prone ventilation when:
• PF > 150 for 6 hrs in the supine position AND PEEP is less than or equal to 12
• Ventilation in the supine condition is possible with safe lung mechanics (ΔP< 14, plateau < 30).
• A repeated attempt results in minimal or no improvement in PF
 Post Intubation

• Target sats 88-95% (PaO2 55-80) ARMA, LOVES, OSCILLATE

• Schjorring et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic
Respiratory Failure. N.Eng. J. Med. 2021 Apr 8;384(14):1301-1311 HOT-ICU
Trial
• Enrolled 2928 patients across 35 ICUs in 7 countries
• Lower oxygenation group: N = 1441 Higher oxygenation group: N = 1447
• Mean age: 70 years (range 60-77)
Median PaO2/SaO2
• Low O2: 70.8 mm Hg (range 66.6 – 76.5) / Low O2: 93% (range 92-94)
• High O2: 93.3 mm Hg (range 87.1 – 98.7) / High O2: 96% (range 95-97)
90-day Mortality
• Low O2: 42.9% vs High O2: 42.4%
• RR: 1.02 (95% CI 0.94 to 1.11; p = 0.64) - no difference
Median % Days Alive Without Life Support
• Low O2: 87.8% (range 0.0 – 96.7) vs High O2: 84.4% (range 0.0 – 96.0)
• P = 0.10 No statistical difference
 Post Intubation

• Inhaled Flolan/iNO may be used as a rescue strategy for refractory hypoxemia

• No survival benefit despite improvement in oxygenation
• ? increased renal dysfunction
• heterogeneity in all cases
• documented right heart failure or intra-cardiac R to L shunt with hypoxemia
 Thrombosis

P-CAP - Randomized, Embedded, Multi-factorial Adaptive Platform Trial for Community-Acquired Pne
4 - Therapeutic Anticoagulation; Accelerating COVID-19 Therapeutic Interventions and Vaccines-4
C - Antithrombotics Inpatient;  and Antithrombotic Therapy to Ameliorate Complications of COVID-19

0 - Paused the trials for severe covid-19

- Therapeutic doses of heparin - increased mortality & greater requirement for oxygen support.
- bleeding also increased
- Paused the trials for moderate covid - 19
- superiority of anticoagulation at therapeutic doses
- outcome of survival or reduced requirement for organ support
 COVID 19 Critical Care Resources

• https://icu-pandemic.org
• Site collates national and international guidance
and resources

• ATS/ESICM/SCCM Guideline
• JAMA Advances in Diagnosis and Treatment 2018
• Osler ARDS Orderset