-
Berlin Criteria1 require all these for ARDS dx: - Timing: w/in 1wk of known clinical insult or new/worsening resp sx
- BL opacities on chest imaging (CXR, CT) not fully explained by effusions, nodules, lobe/lung collapse
- Resp failure not fully explained by cardiac failure or fluid overload (if no ARDS risk, objectively exclude hydrostatic edema, eg, w/ echo)
- Hypoxemia mod/severe. PaO2/FiO2 ratio ≤300 mmHg on PEEP (or CPAP2) ≥5 cmH2O.1 If PaO2 not available: SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated pt), per WHO2
Use PaO2/FiO2 ratio to determine ARDS severity (in mmHg, modify for elevated altitude)1,2 - Mild: PaO2/FiO2 >200 but ≤300, on PEEP (or CPAP2) ≥5 cmH2O
- Moderate: PaO2/FiO2 >100 but ≤200, on PEEP ≥5 cmH2O
- Severe: PaO2/FiO2 ≤100, on PEEP ≥5 cmH2O
Footnotes 1 The ARDS Definition Task Force 2012. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA. 2012;307(23):2526–2533. Accessed 3/23/20
• Altitude elevation. Correct PaO 2/FiO 2 ratio for altitude >1000 m: (PaO 2/FiO 2)x(barometric pressure/760).
2 WHO 2021. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 1/29/21
Mild ARDS (PaO2/FiO2 201-300) Isolate pt & use droplet/contact precautions if COVID-19 suspected/confirmed. Maintain O2 sat w/ mechanical ventilation (or select noninvasive options1,2 early in course) - Consider trial of HFNO, NIV in select pts;1 (HFNO preferred over NIV, per NIH2 & ACP3)
- Intubation. Oral preferred vs nasal to ↓risk of VAP in adolescent/adult; rapid-sequence OK after assessment.1 Pre-oxygenate1 w/ 100% FiO2 x5min, as rapid desat common during intubation, esp if pregnant or obese.1 Airborne precautions given concern about COVID-19 aerosolization.1 Video laryngoscopy by most experienced provider preferred, per ESICM/SCCM,4 NIH2
- Lower TV: 4-8mL/kg PBW per ATS, NIH, WHO, ESICM/SCCM;1,2.4,5 ≤6 mL/kg per ICS.6 Start 6 mL/kg PBW,1,5 increase to 8 if required.1,5 Target PP <30 cmH2O.1,2,4,5 Permissive hypercapnia OK1
- Titrate PEEP. Avoid vent disconnection (eg, for transport, suction)1
- Maintain SpO2: 92%-96%, per ESICM/SCCM,4 NIH2 ≥90%, per WHO (92%-95%, if pregnant)1
- Obtain cultures: blood + LRT cx recommended by WHO.1 LRT samples preferred for COVID-19 testing, per ESICM/SCCM4
Adjunctive tx as needed to achieve oxygenation - Sedation OK if needed to achieve targets1
- Neuromuscular blockade: routine NMBA not recommended by WHO, ESICM/SCCM, ICS;1,4,6 OK if needed, per NIH, but with caution2
- Position. Consider proning all severely ill pts requiring supplemental O2 (incl HFNO) or non-invasive ventilation, per WHO;1 consider trial of proning to improve SpO2 only if intubation not otherwise indicated, per NIH;2 semi-recumbent position (head of bed up 30-45°) favored by ESICM/SCCM, ICS for mild ARDS4,6
- Fluids. Conservative IVF strategy2,4,6 in pts w/o tissue hypoperfusion1
- Consider empiric abx for CAP, per WHO,1 ESICM/SCCM;4 insuff evidence, per NIH;2 de-escalate ASAP
- Meds for COVID-19: No drugs are FDA-approved for COVID-19 (link to Consensus Guidelines for COVID-19 Drug Therapies in epocrates)
- Corticosteroids: dexamethasone (6 mg/day x10 days) recommended if pt on supplemental O2 or mechanical vent2,7
- VTE prophylaxis recommended at usual ppx dosing for all nonpregnant pts hospitalized w/ COVID-19; eval for thromboembolic dz if rapid deterioration or sudden perfusion loss1,2
- Not recommended: HFOV,6 inhaled nitric oxide2,4,5
Footnotes 1 WHO 2021. World Health Organization. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 1/29/21
• HFNO or NIV to manage hypoxemic resp failure: recommended only in pts w/o hemodynamic instability, multiorgan failure, or altered mental status; if trialed, monitor closely for deterioration.
• Pre-oxygenation method: face mask w/ reservoir bag, bag-valve mask, HFNO, or NIV all appropriate.
• Intubation. Intubation by experienced provider using airborne precautions
• TV: Increase from 6 mL/kg up to 8 mL/kg if required d/t dyssynchrony, pH <7.15, etc.
• Recruitment maneuvers: Conditionally recommended by guidelines; monitor pt to see who responds to initial higher PEEP or a recruitment maneuver protocol, stopping if non-response. Avoid combo of high PEEP + prolonged high-pressure maneuvers.
• Prone position. In pregnant pts: little evidence; may benefit from lateral decubitus position.
• Neuromuscular blockade not routine, may be considered if ventilator dyssynchrony despite sedation limits TV, refractory hypoxemia/hypercapnia.
2 NIH 2020. NIH COVID-19 Treatment Guidelines. Last updated 12/17/20. Accessed 1/29/21
• NIH recommends HFNO over NIV, but a closely monitored trial of NIV is recommended if HFNO not available
• Intermittent bolus or continuous NMBA recommended if needed to facilitate protective lung ventilation; however, doing so may require increased HCW exposure and PPE use, HCW risk may outweigh benefit of NMBA
3 ACP 2021. Qaseem A, et al. Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021. April 27. DOI:10.7326/M20-7533. PDF
4 ESICM/SCCM 2020. Alhazzani W, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults With Coronavirus Disease 2019 (COVID-19). March 2020. PDF
5 ATS/ESICM/SCCM 2017. Fan E, 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 Resp Crit Care. 2017 May 1;195(9):1253-1263. PDF
• PBW Male = 50 + 0.91 (height in cm - 152.4) kg
• PBW Female = 45.5 + 0.91 (height in cm - 152.4) kg
• TV: Increase from 6 mL/kg up to 8mL/kg if required d/t pt double-triggering or if inspiratory airway pressure drops below PEEP.
6 ICS 2018. Intensive Care Society. Guidelines on Management of Acute Respiratory Distress Syndrome. Version 1. July 2018. PDF
7 IDSA 2020. Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 Infection. 11 Apr 2020. Accessed 6/29/20
Equivalent daily corticosteroid doses:
• dexamethasone 6 mg
• methylprednisolone 32 mg
• prednisone 40 mg
Moderate/severe ARDS (PaO2/FiO2 ≤200) Isolate pt & use droplet/contact/airborne precautions if COVID-19 suspected/confirmed. Use mechanical ventilation1 + adjunctive care to maintain O2 sat - Intubation. Oral preferred vs nasal to ↓risk of VAP in adolescent/adult; rapid-sequence OK after assessment.1 Pre-oxygenate1 w/ 100% FiO2 x5min, as rapid desat common during intubation, esp if pregnant or obese.1 Airborne precautions given concern about COVID-19 aerosolization.1 Video laryngoscopy by most experienced provider preferred, per ESICM/SCCM,2 NIH3
- Lower TV: 4-8mL/kg PBW per ATS, NIH, WHO, ESICM/SCCM;1-4 ≤6 mL/kg per ICS.5 Start 6 mL/kg PBW,1,4 increase to 8 if required.1,4 Target PP <30 cmH2O;1-4 ≤30 for pts w/ PaO2/FiO2 ≤150 mmHg, per ICS.5 Permissive hypercapnia OK1
- Higher5 PEEP favored in mod/severe ARDS1-3,5 (conditional recommendation, per ATS).4 Avoid vent disconnection (eg, for transport, suction).1 If using recruitment maneuvers4 in mod/severe ARDS, don't staircase;2,3 do monitor for response1
- Maintain SpO2: 92%-96%, per ESICM/SCCM, NIH;2,3 ≥90%, per WHO (92%-95% if pregnant)1
- Obtain cultures: blood + LRT cx recommended by WHO.1 LRT samples preferred for COVID-19 testing, per ESICM/SCCM2
Adjunctive tx as needed to achieve oxygenation - Sedation OK prn to achieve TV targets1
- Position. For mod/severe ARDS, prone ≥12h/day, per ICS,5 12-16h/day, per WHO,1 ESICM/SCCM,2 NIH;3 per ATS, prone position ≥12h/day only in severe ARDS4
- Fluids. Conservative IVF strategy2,3,5 in pts w/o tissue hypoperfusion1
- Consider empiric abx for CAP, per WHO,1 ESICM/SCCM;2 insuff evidence, per NIH;3 de-escalate ASAP
- Corticosteroids: dexamethasone (6 mg/day x10 days) recommended if pt on supplemental O2, mechanical vent, ECMO3,6
- Neuromuscular blockade not routine, per WHO,1 but cisatracurium besylate continuous 48h-infusion suggested early in the course (eg, 1st 48h) of pts w/ PaO2/FiO2 ratio <150, per ICS;5 consider 24h-infusion if proning, per ESICM/SCCM;2 OK if needed, per NIH, but w/ caution3
- Inhaled NO trial recommended by NIH in severe ARDS not responding to other measures;3 not recommended by ICS5
- ECMO: Not routine; consider if refractory hypoxemia despite lung-protective ventilation, per ATS, WHO, ESICM/SCCM, NIH;1-4 in very severe pts, per ICS5
- Meds for COVID-19: No drugs are FDA-approved for COVID-19; (link to Consensus Guidelines for COVID-19 Drug Therapies in epocrates)
- VTE prophylaxis recommended at usual ppx dosing for all nonpregnant pts hospitalized w/ COVID-19; eval for thromboembolic dz if rapid deterioration or sudden perfusion loss1,3
- Not recommended: HFOV4,5
Footnotes 1 WHO 2021. World Health Organization. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 1/29/21
• HFNO or NIV to manage hypoxemic resp failure: recommended only in pts w/o hemodynamic instability, multiorgan failure, or altered mental status; if trialed, monitor closely for deterioration.
• Pre-oxygenation method: face mask w/ reservoir bag, bag-valve mask, HFNO, or NIV all appropriate.
• Intubation. Intubation by experienced provider using airborne precautions.
• TV: Increase from 6 mL/kg up to 8 mL/kg if required d/t dyssynchrony, pH <7.15, etc.
• Recruitment maneuvers: Conditionally recommended by guidelines; suggest monitoring pt to see who responds to initial higher PEEP or a recruitment maneuver protocol, stopping if non-response. Avoid combo of high PEEP + prolonged high-pressure maneuvers.
• Prone position. Little evidence in pregnant pts; may benefit from lateral decubitus position.
• Neuromuscular blockade not routine, may be considered if ventilator dyssynchrony despite sedation limits TV, refractory hypoxemia/hypercapnia.
2 ESICM/SCCM 2020. Alhazzani W, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults With Coronavirus Disease 2019 (COVID-19). March 2020. PDF
Though role of corticosteroids is unclear in setting of COVID-19, ESICM/SCCM weakly favors “using corticosteroids over not using corticosteroids” in mech ventilated ARDS pts w/ COVID-19.
3 NIH 2020. NIH COVID-19 Treatment Guidelines. Last updated 12/17/20. Accessed 1/29/21
• NIH recommends HFNO over NIV, but a closely monitored trial of NIV is recommended if HFNO not available
• Intermittent bolus or continuous NMBA recommended if needed to facilitate protective lung ventilation; however, doing so may require increased HCW exposure and PPE use, HCW risk may outweigh benefit of NMBA
• Proning requires increased HCW exposure to prevent ET tube, catheter dislodgement, and in setting of PPE shortage, HCW risk may outweigh benefit of proning
4 ATS/ESICM/SCCM 2017. Fan E, 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 Resp Crit Care. 2017. May 1;195(9):1253-1263. PDF
• PBW Male = 50 + 0.91(height in cm - 152.4) kg
• PBW Female = 45.5 + 0.91(height in cm - 152.4) kg
• TV: Increase from 6 mL/kg up to 8mL/kg if required d/t pt double-triggering or if inspiratory airway pressure drops below PEEP.
• Higher PEEP, recruitment maneuvers. Conditional recommendation for these in mod/severe ARDS.
• ECMO. Additional evidence required to form recommendations.
5 ICS 2018. Intensive Care Society. Guidelines on Management of Acute Respiratory Distress Syndrome. Version 1. July 2018. PDF
• ICS notes low quality evidence, but consistent lack of mortality benefit w/ inhaled NO, associated w/ increased risk of renal dysfxn.
6 IDSA 2020. Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 Infection. 11 Apr 2020. Accessed 6/29/20
Equivalent daily corticosteroid doses:
• dexamethasone 6 mg
• methylprednisolone 32 mg
• prednisone 40 mg
-
Use criteria1,2 for ARDS dx (all required) - Timing: w/in 1wk of known clinical insult1,2 or new/worsening resp sx1
- BL opacities on chest imaging (CXR, CT) not fully explained by effusions, nodules, lobe/lung collapse per WHO;1 new infiltrates c/w acute parenchymal dz, per PALICC2
- Pulm infiltrates & resp failure1/hypoxemia not fully explained by cardiac failure or fluid overload1 (incl in pts w/ LV heart dysfxn);2 if no ARDS risk, objectively exclude hydrostatic edema, eg, w/ echo, per WHO1
- Hypoxemia. OI ≥4 or OSI ≥5 in invasively ventilated pts1 (OI preferred2); PaO2/FiO2 ≤300 mmHg or SpO2/FiO2 ≤264 in pts on bilevel NIV or CPAP w/ ≥5 cmH2O1 (PaO2/FiO2 preferred2)
Use OI1,2 to determine ARDS severity in invasive ventilated pts. Use PaO2/FiO2 ratio1,2 in pts on CPAP/BiPAP w/ ≥5 cmH2O.1,2 ARDS severity:1,2 - Mild: OI ≥4 OI but <8; or OSI ≥5 but <7.5 (invasively ventilated)
- Moderate: OI ≥8 OI but <16; or OSI ≥7.5 but <12.3 (invasively ventilated)
- Severe: OI ≥16 or OSI ≥12.3 (invasively ventilated)
Footnotes 1 WHO 2021. World Health Organization. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 1/29/21
• OI = (FiO 2×Paw×100)/PaO 2.
• OSI = (FiO 2×Paw×100)/SpO 2.
• PaO2-based dx measure preferred; if not available, wean FiO 2 to ≤97% for OSI or SpO 2/FiO 2 calc.
• Altitude elevation. Correct PaO 2/FiO 2 ratio for altitude >1000 m: (PaO 2/FiO 2)x(barometric pressure/760).
• NIV for hypoxemic resp failure recommended only in select pts.
• Bubble nasal CPAP may be used and may be more available for newborns and children w/ severe hypoxemia. Use airborne precautions.
2 PALICC 2015. The Pediatric Acute Lung Injury Consensus Conference Group. Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations From the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015 Jun;16(5):428-439. PDF
• For ARDS dx using SpO2 criteria: Titrate oxygen to SpO 2 88%-97%.
• Invasive ventilated pts: If OI unavailable for determining ARDS severity, use OSI.
• CPAP/BiPAP pts w/ ≥5 cmH2O: If PaO 2/FiO 2 ratio unavailable for determining ARDS severity, use O 2sat/FiO 2 ratio.
Mild ARDS (OI <8 or OSI <7.5) Isolate pt & use droplet/contact precautions if COVID-19 suspected/confirmed. Maintain O2 sat w/ mechanical ventilation (or select noninvasive options1 early in course) - Intubation. Oral preferred vs nasal to ↓risk of VAP in adolescent; rapid-sequence OK after assessment.1 Pre-oxygenate1 w/ 100% FiO2 x5min, as rapid desat common during intubation, esp in young child, pregnant, or obese.1 Airborne precautions given concern about COVID-19 aerosolization.1 Video laryngoscopy by most experienced provider preferred, per NIH2
- Adapt TV to dz severity, btwn 3-8 mL/kg PBW depending on compliance1,3
- Permissive hypercapnia: pH 7.15-7.30 permitted in children, per WHO1
- Titrate PEEP at mod-elevated levels (eg, 10-15 cmH2O);3 max PEEP 15 in younger children, per WHO.1 Target PP <28 cmH2O3
- Recruitment. Use careful recruitment maneuvers (not sustained inflation);3 if used, monitor response,1 avoid staircase.2 Avoid vent disconnect (eg, for transport, suction)1
- Maintain SpO2 92%-97% for mild dz w/ optimized PEEP <10. Consider SpO2 88%-92% if optimized PEEP >10. If SpO2 <92%, monitor central venous sat, etc3
Adjunctive tx as needed to achieve oxygenation - Sedation OK if needed to achieve targets1,3
- Position. Consider proning all severely ill pts requiring supplemental O2 (incl HFNO) or non-invasive ventilation, per WHO1
- Fluids. Conservative IVF strategy in pts w/o tissue hypoperfusion;1,2 avoid positive fluid balance3
- Neuromuscular blockade by continuous infusion not routine but consider for some pts, per WHO,1 NIH;2 consider if sedation alone inadequate, per PALICC3
- Corticosteroids: dexamethasone (6 mg/day x10 days) recommended if pt on supplemental O2 or mechanical vent2
- Consider empiric abx for CAP, per WHO,1 de-escalate ASAP
- Meds for COVID-19: No drugs are FDA-approved for COVID-19; (link to Consensus Guidelines for COVID-19 Drug Therapies in epocrates)
- VTE prophylaxis recommended at usual ppx dosing for all nonpregnant pts hospitalized w/ COVID-19; eval for thromboembolic dz if rapid deterioration or sudden perfusion loss1,2
- Not recommended: routine inhaled nitric oxide,3 HFJV,3 HFPV;3 insufficient data re chest PT3
Footnotes 1 WHO 2021. World Health Organization. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 6/9/20
• HFNO or NIV to manage hypoxemic resp failure: recommended only in pts w/o hemodynamic instability, multiorgan failure or altered mental status. Use airborne precautions. HNFO has gas flow limits; (children may require adult circuit). If trialed, monitor closely for deterioration.
• Bubble nasal CPAP may be more available in some settings; may be used for newborns/children w/ severe hypoxemia. Use airborne precautions.
• Pre-oxygenation method: face mask w/ reservoir bag, bag-valve mask, HFNO, or NIV all appropriate.
• Intubation. WHO recommends intubation by experienced provider using airborne precautions.
• Recruitment maneuvers: Conditionally recommended by guidelines; however, suggest monitoring pt to see who responds to initial higher PEEP or a recruitment maneuver protocol, stopping if non-response. Avoid combo of high PEEP + prolonged high-pressure maneuvers.
• Prone position. Little evidence in pregnant pts; may benefit from lateral decubitus position.
• Neuromuscular blockade not routine, may be considered if ventilator dyssynchrony despite sedation limits TV, refractory hypoxemia/hypercapnia.
2 NIH 2020. NIH COVID-19 Treatment Guidelines. Last updated 12/17/20. Accessed 1/29/21
• NIH recommends HFNO over NIV, but a closely monitored trial of NIV is recommended if HFNO not available
• Intermittent bolus or continuous NMBA recommended if needed to facilitate protective lung ventilation; however, doing so may require increased HCW exposure and PPE use, HCW risk may outweigh benefit of NMBA
3 PALICC 2015. The Pediatric Acute Lung Injury Consensus Conference Group. Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations From the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015 Jun;16(5):428-439. PDF
• TV. 3-6 mL/kg PBW if poor resp compliance, 5-8 mL/kg if compliance closer to NL.
• PP. Allow slightly higher PP (eg, 29-32 cmH 2O) if chest wall has ↑elastance (eg, ↑compliance). If PP >28 in mod/severe ARDS, w/o evidence of ↓chest wall compliance, consider HFOV.
• HFJV not routine, but if severe air leak syndrome, might consider as HFOV adjunct.
• HFPV not routine, but consider if secretion-induced lung collapse unresponsive to routine care.
• Permission hypercapnia exceptions: IC HTN, severe pulm HTN, certain congenital heart dz, hemodynamic instability, significant ventricular dysfxn. Bicarb supplement not routine for permissive hypercapnia.
• Inhaled nitric oxide: Not routine; consider if known pulm HTN or severe RV dysfxn.
• Neuromuscular blockade: If used, consider daily holiday for reassessment.
Moderate/severe ARDS (OI <8 or OSI <7.5) Isolate pt & use droplet/contact/airborne precautions if COVID-19 suspected/confirmed. Use mechanical ventilation1 + adjunctive care to maintain O2 sat - Intubation. Oral preferred vs nasal to ↓risk of VAP in adolescent; rapid-sequence OK after assessment.1 Pre-oxygenate1 w/ 100% FiO2 x5min, as rapid desat common during intubation, esp in young child, pregnant, or obese.1 Airborne precautions given concern about COVID-19 aerosolization.1 Video laryngoscopy by most experienced provider preferred, per NIH2
- Adapt TV to dz severity, btwn 3-8 mL/kg PBW depending on compliance1,3
- Permissive hypercapnia: Consider for mod/severe dz (exceptions exist); maintain pH 7.15-7.30, per PALICC3
- Titrate PEEP at mod-elevated levels (eg, 10-15 cmH2O);3 max PEEP 15 in younger children, per WHO.1 If severe ARDS, PEEP >15 may be required but keep to PP limits.3 Target PP <28 cmH2O3
- Recruitment. Use careful recruitment maneuvers (not sustained inflation);3 if used, monitor response,1 avoid staircase.2 Avoid vent disconnect (eg, for transport, suction)1
- Maintain SpO2. Consider SpO2 88%-92% if optimized PEEP >10. If SpO2 <92%, monitor central venous sat, etc3
Adjunctive tx as needed to achieve oxygenation - Sedation OK if needed to achieve TV, O2 targets1,3
- Position. Semi-recumbent position (head of bed up 30-45°);1 consider prone position in severe ARDS2,3 if setting capable and PPE supply adequate1,2
- Fluids. Conservative IVF strategy in pts w/o tissue hypoperfusion;1,2 avoid positive fluid balance3
- Neuromuscular blockade by continuous infusion not routine but consider for some pts, per WHO,1 NIH;2 consider if sedation alone inadequate, per PALICC3
- Inhaled nitric oxide: Not routine; consider if known pulm HTN or severe RV dysfxn, if refractory hypoxemia in spite of maximized vent and other rescue strategies,2 or as bridge to ECMO in certain pts3
- ECMO: If refractory hypoxemia despite lung-protective ventilation, consider ECMO, per WHO,1 NIH (in setting of trial),2 and PALICC (for severe dz in certain pts)3
- Consider empiric abx for CAP, per WHO,1 de-escalate ASAP
- Corticosteroids: dexamethasone (6 mg/day x10 days) recommended if pt on supplemental O2, mechanical vent, ECMO2
- Meds for COVID-19: No drugs are FDA-approved for COVID-19; (link to Consensus Guidelines for COVID-19 Drug Therapies in epocrates)
- VTE prophylaxis recommended at usual ppx dosing for all nonpregnant pts hospitalized w/ COVID-19; eval for thromboembolic dz if rapid deterioration or sudden perfusion loss1,2
- Not recommended: HFJV;3 HFPV;3 insufficient data re chest PT3
Footnotes 1 WHO 2021. World Health Organization. COVID-19 Clinical Management: Living Guidance. Updated 1/25/21. Accessed 1/29/21
• HFNO or NIV to manage hypoxemic resp failure: recommended only in pts w/o hemodynamic instability, multiorgan failure, or altered mental status. Use airborne precautions. HNFO has gas flow limits; (children may require adult circuit). If trialed, monitor closely for deterioration.
• Bubble nasal CPAP may be more available in some settings; may be used for newborns/children w/ severe hypoxemia. Use airborne precautions.
• Prone position. Little evidence in pregnant pts; may benefit from lateral decubitus position.
• Neuromuscular blockade not routine, may be considered if ventilator dyssynchrony despite sedation limits TV, refractory hypoxemia/hypercapnia.
2 NIH 2020. NIH COVID-19 Treatment Guidelines. Last updated 12/17/20. Accessed 1/29/21
• NIH recommends HFNO over NIV, but a closely monitored trial of NIV is recommended if HFNO not available
• Intermittent bolus or continuous NMBA recommended if needed to facilitate protective lung ventilation; however, doing so may require increased HCW exposure and PPE use, HCW risk may outweigh benefit of NMBA
• Proning requires increased HCW exposure to prevent ET tube, catheter dislodgement, and in setting of PPE shortage, HCW risk may outweigh benefit of proning
3 PALICC 2015. The Pediatric Acute Lung Injury Consensus Conference Group. Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations From the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015 Jun;16(5):428-439. PDF
• TV. 3-6 mL/kg PBW if poor resp. compliance, 5-8 mL/kg if compliance closer to NL.
• PP. Allow slightly higher PP (eg, 29-32 cmH 2O) if chest wall has ↑elastance (eg, ↓compliance). If PP >28 in mod/severe ARDS, w/o evidence of ↓chest wall compliance, consider HFOV.
• HFJV not routine, but if severe air leak syndrome, might consider as HFOV adjunct.
• HFPV not routine, but consider if secretion-induced lung collapse unresponsive to routine care.
• Permission hypercapnia exceptions: IC HTN, severe pulm. HTN, certain congenital heart dz, hemodynamic instability, significant ventricular dysfxn. Bicarb supplement not routine for permissive hypercapnia.
• ECMO: when ARDS cause is reversible, or pt suitable lung txp candidate. Also consider if known pulm HTN or severe RV dysfxn.
• Neuromuscular blockade: If used, consider daily holiday for reassessment.
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