Mechanical Ventilation in COVID-19: Interpreting the Current Epidemiology

Abstract

Right now the world is scrutinizing every cohort and every outcome for COVID-19 patients, particularly the most critically ill who are receiving mechanical ventilation. The numbers that have been published are all over the place, and some of them -such as very high mortalityare causing panic. Two major issues are at play in these epidemiological studies. The first is when to intubate, and assessment of the rates of intubation and mechanical ventilation for hospitalized patients in cohorts from across the world. The second is the reported mortality for patients who receive mechanical ventilation. Presentation and interpretation of the data for both of these issues is not straightforward, and never has been. However, there are ways we can improve assessment of these cohort studies. The decision to ventilate"He claimed that the Americans had put their patients in the respirators far too early -certainly they would not have been ventilated in Copenhagen. It's no wonder they survived, he claimed, because they didn't need treatment in the first place (1)." That is not a quote from 2020, but is from Dr. Henry Lassen in 1952. He and his team were dealing with an overwhelming polio epidemic and a high rate of respiratory failure among his patients and he was scrutinizing data from California. It turns out that the same debate we are now having regarding early versus late(r) use of mechanical ventilation and when patients need to receive mechanical ventilation has been going on since the birth of intensive care seventy years ago (2). Conscientious writers and editors have always insisted on describing patients as having"received" mechanical ventilation, rather than having a "need" for mechanical ventilation because we have never fully agreed on who is in need. What may have seemed like quibbling

Respiratory management of adult patients with acute respiratory distress syndrome due to COVID‐19

“…Larger epidemiological studies have reported rates of invasive mechanical ventilation ranging from 2.3% to 33.1% of hospitalized COVID-19 patients and 29.1% to 89.9% among patients admitted to the intensive care unit (ICU). 7 Risk factors of ARDS and need for ICU admission include age >60 years, male gender and comorbidities such as heart disease, diabetes mellitus, chronic lung disease, immunocompromised state and malignancy. 3 Given that COVID-19 may cause hypoxia with minimal respiratory distress ('silent hypoxia'), the threshold for intubation should be lower particularly for those patients with persistent hypoxia despite escalation to HFNO and exhibiting shortness of breath.…”

“…Table 1 provides a summary of the oxygen therapies and ventilator strategies employed by ICU globally to treat patients with COVID-19 respiratory failure. 7 Most recently, based on the results of the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, corticosteroids (i.e. dexamethasone 6 mg per day for up to 10 days) are recommended for patients who are mechanically ventilated, and in patients who require supplemental oxygen but who are not mechanically ventilated.…”

Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm

“…These patients usually require a prolonged period of mechanical ventilation, 3 to 4 weeks, with high mortality. 19,20 In addition to strict isolation, the risk of transmission due to droplet exposure mandates an aggressive approach to sedation and pain management to prevent sudden uncontrolled agitation and/or self extubation. The rate of unplanned extubation reported in different sedation trials, up to 12%, is unacceptably high in this context (►Fig.…”

Managing Patients on Extracorporeal Membrane Oxygenation Support During The COVID-19 Pandemic – A Proposal for A Nursing Standard Operating Procedure

“…The dynamic evolution of the pandemic provides a growing that allows for innovations to optimisations of procedures [6][7][8][9][10][11][12].…”

“…Although estimates are that only 3-5% of all cases progress into critical illness [19], it is signi cant given the high numerator. Invasive mechanical ventilation is necessary for a signi cant number of COVID 19-cases, in both hospitalized and critically ill (2.3-33.1% and 29.1-89.9%, respectively) [12]. The World Health Organization (WHO) provisionally recommends ECMO in cases with refractory hypoxemia unresponsive to lung-protective ventilation emphasizing access to expertise in extracorporeal membrane oxygenation [20].…”