New and personalized ventilatory strategies in patients with COVID-19

Abstract

Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus and may lead to severe respiratory failure and the need for mechanical ventilation (MV). At hospital admission, patients can present with severe hypoxemia and dyspnea requiring increasingly aggressive MV strategies according to the clinical severity: noninvasive respiratory support (NRS), MV, and the use of rescue strategies such as extracorporeal membrane oxygenation (ECMO). Among NRS strategies, new tools have been adopted for critically ill patients, with advantages and disadvantages that need to be further elucidated. Advances in the field of lung imaging have allowed better understanding of the disease, not only the pathophysiology of COVID-19 but also the consequences of ventilatory strategies. In cases of refractory hypoxemia, the use of ECMO has been advocated and knowledge on handling and how to personalize strategies have increased during the pandemic. The aims of the present review are to: (1) discuss the evidence on different devices and strategies under NRS; (2) discuss new and personalized management under MV based on the pathophysiology of COVID-19; and (3) contextualize the use of rescue strategies such as ECMO in critically ill patients with COVID-19.

Keywords: COVID-19; extracorporeal membrane oxygenation; invasive mechanical ventilation; noninvasive respiratory support; prone position; recruitment maneuvers.

Figure 1

Suggested flowchart for noninvasive ventilatory management in COVID-19. APP, awake prone position; HFNC, high flow nasal cannula; LPV, lung protective ventilation; NRS, noninvasive respiratory support; P/F, PaO₂ to FiO₂ ratio; RI, ROX Index; SpO₂, oxygen saturation; WOB, work of breathing; CPAP, continuous positive airway pressure; IMV, invasive mechanical ventilation; PEEP, positive end expiratory pressure.

Figure 2

Suggested flowchart for ventilatory management in COVID-19. Acs MM: Accessories Muscles; ARM, alveolar recruitment maneuver; COT, conventional oxygen therapy; ECMO, Extracorporeal Membrane Oxygenation; IMV, invasive mechanical ventilation; HFNC, high flow nasal cannula; LPV, lung protective ventilation; NMB, neuromuscular blocker; NRS, noninvasive respiratory support; P/F, PaO₂ to FiO₂ ratio; PP, prone position; PSV, pressure support ventilation; RI, ROX Index; SP, supine position; SpO₂, oxygen saturation; ULPV, ultra lung protective ventilation; WOB, work of breathing; CPAP, continuous positive airway pressure; PaO₂, arterial partial pressure of oxygen; FiO₂, fraction of inspired oxygen; FDO₂, fraction of oxygen in the sweep gas stream; PEEP, positive end-expiratory pressure.