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| ==Mechanical ventilation==
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| *The [[COVID-19]] respiratoty complications that may require mechanical ventilation include: [[COVID-19-associated pneumonia]], [[COVID-19-associated acute respiratory distress syndrome]] and [[COVID-19-associated respiratory failure]].
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| ==Ventilatory support==
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| ===Supplemental Oxygen===
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| *Surviving Sepsis Campaign has the following recommendations regarding the use of [[oxygen therapy|supplemental oxygen]] in [[COVID-19]] patients:<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| **It is strongly recommended (with moderate-quality evidence) to start the [[oxygen therapy|supplemental oxygen]] if the [[oxygen saturation|Spo2]] is < 90% in adults. A weak recommendation states starting the supplemental oxygen at < 92% saturation.
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| **In [[COVID-19]] positive adult [[patients]] with acute [[respiratory failure|hypoxemic respiratory failure]] on [[oxygen therapy|supplemental oxygen therapy]], [[oxygen saturation|Spo2]] should be maintained no higher than 96% (strong recommendation by Surviving Sepsis Campaign). This based upon the systematic review and meta-analysis of 25 [[Randomized controlled trial|RCTs]] that showed a linear association between the death risk and higher [[oxygen saturation|Spo2]] targets.
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| ===High Flow Nasal Cannula (HFNC)===
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| *Also known as high flow nasal oxygen (HFNO) or Heated humidified high-flow (HHHF) therapy.
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| *Surviving Sepsis Campaign has the following recommendations regarding the use of HFNC in [[COVID-19]] patients:<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| **In [[COVID-19]] positive adult [[patients]] with acute [[respiratory failure|hypoxemic respiratory failure]] despite [[oxygen therapy|supplemental oxygen therapy]], a weak recommendation suggests using HFNC over conventional [[oxygen therapy]]. A systematic review and meta-analysis of 9 [[Randomized controlled trial|RCTs]] showed that High Flow Nasal Cannula (HFNC) reduces the need for [[intubation]].
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| **A weak recommendation (low-quality evidence) also prefers using HFNC over [[Positive airway pressure|Non-invasive positive pressure ventilation (NIPPV)]]. It is possibly due to reduced [[mortality rate|mortality]] and decreased [[intubation]] risk, as proved by a [[Randomized controlled trial|RCT]] and a meta-analysis respectively. [[Patient]] comfort better oxygenation with HFNC than NIPPV is also one of the considering factors.<ref name="FratThille2015">{{cite journal|last1=Frat|first1=Jean-Pierre|last2=Thille|first2=Arnaud W.|last3=Mercat|first3=Alain|last4=Girault|first4=Christophe|last5=Ragot|first5=Stéphanie|last6=Perbet|first6=Sébastien|last7=Prat|first7=Gwénael|last8=Boulain|first8=Thierry|last9=Morawiec|first9=Elise|last10=Cottereau|first10=Alice|last11=Devaquet|first11=Jérôme|last12=Nseir|first12=Saad|last13=Razazi|first13=Keyvan|last14=Mira|first14=Jean-Paul|last15=Argaud|first15=Laurent|last16=Chakarian|first16=Jean-Charles|last17=Ricard|first17=Jean-Damien|last18=Wittebole|first18=Xavier|last19=Chevalier|first19=Stéphanie|last20=Herbland|first20=Alexandre|last21=Fartoukh|first21=Muriel|last22=Constantin|first22=Jean-Michel|last23=Tonnelier|first23=Jean-Marie|last24=Pierrot|first24=Marc|last25=Mathonnet|first25=Armelle|last26=Béduneau|first26=Gaëtan|last27=Delétage-Métreau|first27=Céline|last28=Richard|first28=Jean-Christophe M.|last29=Brochard|first29=Laurent|last30=Robert|first30=René|title=High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure|journal=New England Journal of Medicine|volume=372|issue=23|year=2015|pages=2185–2196|issn=0028-4793|doi=10.1056/NEJMoa1503326}}</ref>
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| **[[Patient]] should be monitored closely and [[intubated]] in the event of decompensation.
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| ===Non-Invasive Positive Pressure Ventilation===
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| *[[Positive airway pressure|Non-invasive positive pressure ventilation (NIPPV)]] is a technique utilized for delivering mechanical ventilation without the use of [[endotracheal intubation]] or [[tracheostomy]]. It can be administered through a [[Oxygen mask|face mask]], nasal mask, or a helmet.
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| *Many patients who develop [[ARDS]] receive a trial of [[Positive airway pressure|non-invasive positive pressure ventilation (NIPPV)]] before [[intubation]] for [[mechanical ventilation]] before they clinically deteriorate or become unable to maintain adequate [[oxygenation]].
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| *Studies from China reported (4% to 13%) of [[COVID-19]] patients to have received [[Positive airway pressure|non-invasive positive pressure ventilation (NIPPV)]].<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| Invasive mechanical ventilation
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| The Chinese [[CDC]] reports the case-fatality rate to be higher than 50% in [[patients]] who received invasive mechanical ventilation.<ref name="WuMcGoogan2020">{{cite journal|last1=Wu|first1=Zunyou|last2=McGoogan|first2=Jennifer M.|title=Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China|journal=JAMA|volume=323|issue=13|year=2020|pages=1239|issn=0098-7484|doi=10.1001/jama.2020.2648}}</ref>
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| === Alternative Mechanical Ventilation Strategies ===
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| Several specialized modes of [[mechanical ventilation]] have been tested in ARDS, however, none has been proven to carry a [[morbidity]] or [[mortality]] benefit and should only be considered if [[oxygenation]] does not improve with a judicious trial of the first-line mechanical [[ventilation strategies]] as outlined by the ARDS Network.<ref>NIH-NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. "http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf"</ref>
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| *[[Mechanical ventilation modes of ventilation#High Frequency Ventilation (HFV)|'''High-frequency oscillatory ventilation (HFOV)''']] may improve [[oxygenation]] in patients with '''[[Acute respiratory distress syndrome diagnostic criteria|moderate to severe ARDS]] and severe refractory [[hypoxemia]]''', however, initiation of HFOV early in the course of ARDS (i.e., prior to low [[tidal volume]]/high [[PEEP]] [[mechanical ventilation]]) has been associated with ''increased mortality'' compared to lower [[tidal volume]]/high [[PEEP]] ventilation<ref name="pmid12231488">{{cite journal| author=Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG et al.| title=High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial. | journal=Am J Respir Crit Care Med | year= 2002 | volume= 166 | issue= 6 | pages= 801-8 | pmid=12231488 | doi=10.1164/rccm.2108052 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12231488 }} </ref><ref name="pmid23339639">{{cite journal| author=Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P et al.| title=High-frequency oscillation in early acute respiratory distress syndrome. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 9 | pages= 795-805 | pmid=23339639 | doi=10.1056/NEJMoa1215554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23339639 }} </ref>
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| *'''[[Acute respiratory distress syndrome mechanical ventilation therapy#APRV (Airway Pressure Release Ventilation) and ARDS / ALI |Airway pressure release ventilation (APRV)]]''' appears to be safe in ARDS, and may be associated with reduced [[paralytic]] and [[sedative]] use as well as an increase in the number of ventilator-free days<ref name="pmid19727373">{{cite journal| author=Daoud EG| title=Airway pressure release ventilation. | journal=Ann Thorac Med | year= 2007 | volume= 2 | issue= 4 | pages= 176-9 | pmid=19727373 | doi=10.4103/1817-1737.36556 | pmc=2732103 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19727373 }} </ref><ref name="pmid21762559">{{cite journal| author=Daoud EG, Farag HL, Chatburn RL| title=Airway pressure release ventilation: what do we know? | journal=Respir Care | year= 2012 | volume= 57 | issue= 2 | pages= 282-92 | pmid=21762559 | doi=10.4187/respcare.01238 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21762559 }} </ref>
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| ===Recruitment Maneuvers===
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| A '''recruitment maneuver''' is the application of very high (up to 40 cm H<sub>2</sub>O) positive airway pressure to open collapsed [[alveolus|alveoli]], thereby reducing [[Shunt|shunting]], decreasing [[Ventilation-perfusion mismatch|V/Q mismatching]], and improving [[gas exchange]]. The decision to apply recruitment maneuvers must take into account various factors including the extent of lung injury (due to the risk of causing [[barotrauma|volutrauma]] through overdistention of stiff and inflamed lungs) and patient [[hemodynamics]] (due to the risk of further worsening [[hypotension]] by impeding [[venous return]] to the [[right heart]]). Recruitment maneuvers have not been standardized and there are insufficient data to support or discourage their use in ARDS.
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| === Extracorporeal Membrane Oxygenation (ECMO) ===
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| There is growing evidence to support the use of [[extracorporeal membrane oxygenation|extracorporeal membrane oxygenation (ECMO)]] for severe ARDS that fails to improve despite judicious application of the ARDS Network low tidal volume/high PEEP ventilation strategy.<ref name="pmid3090285">{{cite journal| author=Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F et al.| title=Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. | journal=JAMA | year= 1986 | volume= 256 | issue= 7 | pages= 881-6 | pmid=3090285 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3090285 }} </ref><ref name="pmid19762075">{{cite journal| author=Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM et al.| title=Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. | journal=Lancet | year= 2009 | volume= 374 | issue= 9698 | pages= 1351-63 | pmid=19762075 | doi=10.1016/S0140-6736(09)61069-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19762075 }} </ref> ECMO facilitates gas exchange in circumstances where adequate oxygenation and ventilation cannot be achieved through the lungs themselves. There are two main forms of ECMO, both of which have been used successfully in the treatment of [[Acute respiratory distress syndrome diagnostic criteria|severe ARDS]]:
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| *'''Veno-venous (VV)-ECMO''': [[Venous blood]] is removed through an outflow [[cannula]] placed in a large [[vein]] (usually the right [[femoral vein]] or [[inferior vena cava]]) and passed through an [[oxygenator]] where [[gas exchange]] occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in another large vein (usually the right [[internal jugular vein]] or [[superior vena cava]])
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| :*Supports [[gas exchange]] but does not provide any [[hemodynamic]] support
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| *'''Veno-arterial (VA)-ECMO''': Venous blood is removed through an outflow [[cannula]] placed in a large [[vein]] (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where [[gas exchange]] occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in a large [[artery]] (usually the right [[femoral artery]] or right [[carotid artery]])
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| :*Supports [[gas exchange]] and provides [[hemodynamic]] support by bypassing the heart completely
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| The use of ECMO in the treatment of ARDS is an ongoing area of research, and referral to a medical center with ample experience in the use of ECMO for ARDS should be considered for patients with ARDS who are failing traditional management strategies and may be candidates for ECMO. The use of ECMO requires systemic [[anticoagulation]] (usually with [[heparin]]) and is associated with the risk of major [[hemorrhage]] as well as [[thrombosis]]. Additionally, the use of VA-ECMO may result in [[Ischemia|ischemic injury]] to the limb [[distal]] to the site of the inflow [[cannula]] (although rates of limb ischemia have been mitigated by the addition of a [[reperfusion]] cannula that takes blood from the inflow cannula and delivers it distally to the otherwise-affected limb).
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| *[[COVID-19-associated acute respiratory distress syndrome]] (CARDS)
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| The vascular [[endothelium|endothelial]] injury in CARDS and diverse [[mortality rate]]s across the world in CARDS patients arbitrates the importance of different mechanical ventilation strategies.
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| Marini et al. suggest
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| **Lower PEEP: “type L,” characterized by low lung elastance (high compliance), lower lung weight as estimated by CT scan, and a low response to PEEP
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| **Higher PEEP:
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| *'''Lower [[Lung volume|tidal volume]] [[Mechanical ventilation|ventilation]]''' (6 mL/kg predicted body weight) is associated with reduced mortality and a greater number of ventilator-free days<ref name="pmid10793162">{{cite journal| author=| title=Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. | journal=N Engl J Med | year= 2000 | volume= 342 | issue= 18 | pages= 1301-8 | pmid=10793162 | doi=10.1056/NEJM200005043421801 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10793162 }} </ref>
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| :*Lower tidal volume ventilation should be continued even if the [[PaCO2|arterial partial pressure of carbon dioxide (PaCO<sub>2</sub>)]] rises (this is called ''permissive [[hypercapnia]]'')
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| :*Permissive hypercapnia usually results in a drop in blood [[pH]], however, treatment of [[acidemia]] (e.g., intravenous administration of [[sodium bicarbonate]] or [[tromethamine]]) is not indicated if the pH remains at or above 7.15 to 7.20
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| :*Predicted body weight (PBW) in kilograms (kg) may be calculated from height in inches (in) as follows:
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| ::*PBW (men) = '''50 + 2.3 (height in inches – 60)'''
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| ::*PBW (women) = '''45.5 + 2.3 (height in inches – 60)'''
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| *'''Higher [[positive end-expiratory pressure|positive end-expiratory pressure (PEEP)]]''' combined with lower tidal volume ventilation is associated with decreased mortality in patients with '''moderate or severe ARDS (PaO<sub>2</sub>/FIO<sub>2</sub> ≤ 200)'''<ref name="pmid20197533">{{cite journal| author=Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD et al.| title=Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. | journal=JAMA | year= 2010 | volume= 303 | issue= 9 | pages= 865-73 | pmid=20197533 | doi=10.1001/jama.2010.218 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20197533 }} </ref>
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| *'''[[Mechanical ventilation initial ventilator settings#Proning|Prone positioning''']] for at least 16 consecutive hours each day is associated with improved 28-day and 90-day survival in patients with '''ARDS and a PaO<sub>2</sub>/FIO<sub>2</sub> ratio < 150 on an FIO<sub>2</sub> ≥ 60% and PEEP ≥ 5 mmHg'''
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| :*Prone positioning is thought to improve [[oxygenation]] by improving [[Ventilation/perfusion ratio|ventilation/perfusion (V/Q) mismatching]] via reduced [[Shunt|shunting of blood]] through under-ventilated lung tissue
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| *'''[[Cisatracurium]]''', when started within the first 48 hours of ARDS diagnosis and continued for 48 hours, has been associated with improved 90-day survival, a greater number of ventilator-free days, and a decreased incidence of [[barotrauma|volutrauma]]<ref name="pmid20843245">{{cite journal| author=Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A et al.| title=Neuromuscular blockers in early acute respiratory distress syndrome. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 12 | pages= 1107-16 | pmid=20843245 | doi=10.1056/NEJMoa1005372 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20843245 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21242357 Review in: Ann Intern Med. 2011 Jan 18;154(2):JC1-3] </ref>
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| === ARDS Network Mechanical Ventilation Protocol ===
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| ==References==
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| {{Reflist|2}}
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| [[Category:Pick One of 28 Approved]]
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| {{WS}}
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| {{WH}}
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