COVID-19-Associated ARDS Should Be Managed According to Standard Guidelines

By Will Boggs MD

July 15, 2020

NEW YORK (Reuters Health) - Current evidence-based guidelines should be used to manage acute respiratory distress syndrome (ARDS) associated with COVID-19, researchers report.

In the face of heterogeneous clinical features and courses of COVID-19-associated ARDS, several groups have proposed different management strategies on the basis of described phenotypes.

Dr. Eddy Fan of the University of Toronto and University Health Network and Sinai Health System, in Canada, and colleagues strongly recommend adherence to evidence-based management of ARDS in their viewpoint article in The Lancet Respiratory Medicine.

They note that large observational studies suggest that patients with COVID-19-associated ARDS have similar respiratory system mechanics to patients with ARDS from other causes. For most patients, they conclude, "COVID-19-associated ARDS is, in the end, ARDS."

First, the authors recommend lung protection with volume-limited and pressure-limited ventilation, which has been shown to be effective in a heterogeneous ARDS population with a wide range of physiological parameters.

Second, they say, the acceptable degree of hypercapnia in a given patient should depend in part on any associated metabolic acidosis or hemodynamic instability, rather than automatically permitting hypercapnia through the use of lower tidal volumes.

Third, decisions regarding the optimal point at which to intubate a given patient should depend on the presence of refractory hypoxemia or hypercapnia and on objective evidence of high work of breathing.

Finally, individualization of positive end-expiratory pressure (PEEP) is necessary because the response to PEEP differs on the basis of individual respiratory mechanics. PEEP, the authors say, should be targeted to improve oxygen delivery while mitigating the risk of ventilator-induced lung injury and self-inflicted lung injury.

Patients with moderate-to-severe COVID-19-associated ARDS should receive prone positioning, and patients with severe ARDS might require venovenous extracorporeal membrane oxygenation (ECMO), as indicated in international guidelines for ARDS.

"Clinicians should adapt their management plan to each patient," the authors conclude, "accounting for their individual characteristics, as well as their preferences and values - the advice is not a one-size-fits-all approach."

Dr. Joao Carlos Winck of Faculdade de Medicina da Universidade do Porto, in Portugal, who recently reviewed noninvasive respiratory management of COVID-19, told Reuters Health by email, "Until proven contrary in COVID-19-associated ARDS, a lung-protective approach, with volume-limited and pressure-limited ventilation could be recommended."

"In my point of view, it is also very important that pre-ICU optimization of the best non-invasive oxygenation strategies be implemented to reduce the intubation rate and mortality," said Dr. Winck, who was not involved in the article. "Both high-flow nasal oxygen (HFNO) and non-invasive ventilatory support (via oronasal mask and circuit with viral filter) should be tried in a protective environment."

Dr. Winck added, "Our patients and families should not rely on every (bit of) social media news, which is based normally on anecdotal experience and case reports rather than evidence-based medicine. Each hospital/state/country should make public the protocols/management plans and the outcomes of COVID-19 patients undergoing treatment at the different facilities/units."

Dr. Fan did not respond to a request for comments.

SOURCE: https://bit.ly/2WiwgCB Lancet Respiratory Medicine, online July 6, 2020.

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