Coronavirus Collaboration - Summary Version

• Caused by a virus thought to be Droplet Transmission but also evidence for Airborne.
• Incubation is thought to be 2-14 days after exposure (average is 5 days)   
• Imaging: CXR if resources are limited, otherwise consider CT scan. Daily CXR on stable intubated not indicated. 

Some have suggested multiple phenotypes for the virus (no data to support), each with a different clinical progression (Gattinoni, et. al; ESICM)

• Phenotype L: focus is on disregulation of pulmonary perfusion (Low elastance, Low V/Q, Low recruitability, Low PEEP response)
  
• Phenotype H: focus is on pulmonary edema/collapse - ARDS-like (High lung elastance, Higher recruitability, High Right-to-Left shunt, Higher PEEP response)
  
  

Note that while onset of symptoms, such as dyspnea, is relatively late (around 6-7 days after symptoms start), the progression to distress/need for vent is quick. 

• Increased O2 needs, especially if supplemental O2 doesn't increase SpO2/PaO2 (suggesting V/Q imbalance) 
  • Consider intubation once SpO2 < 90-92% with FIO2 0.60 or higher (CP; ESICM)
• Tachypnea (RR > 30) is quite common with distress,
• Indications of shortness-of-breath (speaking in shorter sentences, for example), Dyspnea 

Remember: Protect yourself and others from potential exposures. Equipment must be worn correctly to be effective (See CDC 3 Keys for Respiratory Effectiveness, See CDC Mask Seal Self-Check)

Our Summary: 

• Evidence is consistently emerging to support aerosolized transmission risks at all times. This is supported also by rate of transmission.  
• It is important to recognize that while we use the term airborne to refer to a certain diameter size (MMAD), indeed droplets can still become aerosolized and travel beyond 6-feet 
• There is absolute evidence to support certain activities guaranteeing airborne transmission (see list below in this section), and these should be performed using airborne precautions (including N95 or higher mask), without exception.  It is our belief that if adequate PPE is not available, those so-called aerosol-producing procedures simply cannot be performed in a safe manner. 
• Studies of "viral load" support that greatest risk is closest to the patient, and when performing aerosol-generating-procedures.  
• In our thinking: if there is any increased risk, and certianly there seems to be, the higher level of protection should be strictly followed (N95 or above). While we understand PPE shortages are driving difficult decisions, for adequate healthcare provider protection, this is a necessity.  

• Clinicians who are reusing N95 masks report placing a surgical mask over the N95 to protect it some

Intubation

Do not delay intubation if the patient is worsening or is pre-code (unstable) - Proactive Intubation is Preferred (APSF)

If trialing HFNC or BiPAP/CPAP: if no improvement within 1-2 hours (distress, RR, P/F<150), intubation is recommended (Meng, et. al)

Intubation is high-risk for exposure - take every precaution possible.

Preparation

• Personal Protective Equipment: Airborne (a must!) + Contact = N95 or higher, gown, gloves, goggles/face shield 
• Least # people possible in room, close door during intubation and for a period after, consider enclosure or loose plastic sheet over pt's head
• Fiberoptic equipment is highly recommended.  
• Either NO bagging (use NRB) or place filter in between bag and mask - give gentle breaths only
• Ventilator should be ON, in STAND-BY, place ETCO2 adapter if available, in-line suction
• There is no "Emergency" intubation - all PPE must be donned appropriately to minimize risk

During Intubation

• Person with most experience should intubate
• Use RSI unless difficult airway 
• Have 2 people confirm ET tube through vocal cords using video laryngoscope 
• Bag gently (if using) in between attempts. Max 2-3 attempts, then LMA or similar. 

Post-Intubation

• Finger occlude ET tube as soon as it is placed and stylet out, then place on vent (or bag), Clamp ET tube if any delay (Kelly Clamps, 4x4 Gauze)
• Intubate, place directly on vent - confirm tube placement on vent 

Extubation 

• Most prefer a protected extubation which means treating as a very high-risk procedure and minimizing exposures at each step
• Limit the number in the room (preferably 2) 
• See Recommended Procedure in Full Collaboration 
• Unplanned extubation: turn off vent, place on NRB mask immediately to avoid aerosolization 
• Terminal Wean: consider CPAP 5/5 21% instead of terminal extubation 
• Post-Mortem: Turn off vent, clamp tube, leave tube in 

General Airway Management 

All tasks should be performed with the goal of minimizing exposures, avoiding aerosolization of secretions

• Minimize disconnects from vent whenever possible
• When disconnecting from vent circuit:
  • consider clamping endotracheal tube (use flat Kelly Clampwith a 4x4 gauze) 
  • Vent in stand-by mode prior to disconnecting/clamping
  • If bagging, ensure HEPA/viral filter between airway and bag 

Oxygenation Targets

Oxygen Delivery

Oxygenation Progression of Care, may deteriorate quickly 

SpO2 Goals

• Adults: 88%-96% (many prefer 92-96% as acceptable) 
• COPD:  do not withhold oxygen, consider 88% lower threshold     

Many clinicians are reporting a consensus in progression of care:

1. Initiate with Nasal Cannula (WHO recommends starting at 5 L/min)
2. Progress to 6 L/min (some avoid humidifying)
3. Switch either to nonrebreather mask (15+ L/min) or going directly to intubation. Proactive intubation is advised.
   *If increased WOB after O2, V/Q mismatch may exist and intubation is indicated

No consensus on use of NPPV as a bridge to avoid intubation, or as a bridge for post-extubation.  

Treat as airborne, negative pressure room preferred 

If indications of instability, intubate:  GCS < 10, vasopressors, P/F < 200

HFNC is preferred noninvasive method 

• Ensure prongs are fit and positioned correctly 
• Place surgical mask over patient's mouth/nose (study has shown this reduces aerosolization) 
• Some consider lower rates of flow (30 L/min as max) 
• Stop flow before removing device 

Noninvasive CPAP

• Prefer dual-limb circuit (filter expiratory side) over single-limb circuit (use circuit with filtered leak port, not a mask with leak port)
• Use lowest pressures possible to achieve SpO2 or PaO2 goal 
• Stop flow before removing device 
• Trial for an hour, maybe 2, then reassess - patient should show improvement 

Noninvasive NPPV/BiPAP

• Same as NIV CPAP as above 
• High respiratory drive may damage lungs 
• Use dual-limb, filtered circuit, non-vented mask 

Please review phenotypes for best way to support patients on ventilators.  For patients that meet basic criteria for ARDS, treat with ARDSnet (high PEEP, low VT). For patients with higher compliance, consider treating with lower PEEP, normal (8 mL) VT

NIV for Invasive 

• Do not use basic CPAP machines for invasive (no ventilation support, difficult to provide higher FIO2s)
• See other recommendations in the full collaboration page 
• Mode: S/T or PC, IPAP 25, EPAP 12 (driving pressure = 13, adjust IPAP for 6 mL), RR 25, TI 0.8, FIO2 1.0 

Ventilators

For specific ventilator advice, consider PSRC (Pennsylvania Society) - including stockpile ventilators

• Use HEPA filters on vents (recommend treating as airborne for now), or viral/bacterial filter if HEPA unavailable 
• Some clinicians are reporting atypical lung compliances (higher than expected, >30)) with very low P/F ratios (< 100). It is highly suggested that lung protective strategies are still followed carefully.  See notes above, also, on phenotype theory. 

Goals 

• if ARDSnet = Pplat < 30, pH > 7.25 (some allow as low as 7.15-7.20), PaO2 > 60

Initial Settings

• Tidal Volume (VT)
  • Start at 6 mL/kg IBW.  Decrease by 1 mL/kg as low as 4 mL/kg if Pplat > 30
  • If dyssynchrony and Pplat okay, consider increasing by 1 mL/kg but no higher than 8 mL/kg
• Rate 
  • Start around 20/min, do not exceed 35/min (remember, goal is for acceptable pH, not normalized CO2)
• PEEP
  • Optimal PEEP maneuver if able, check for PEEP-responsiveness 
  • If PEEP-responsive, use PEEP 10-12, sometimes higher (20+ has been reported) - be aware of high PEEP and cardiac function 
  • Maintain driving pressure (Pplat - PEEP) of under 12-15 
• FIO2
  • Prioritize use of PEEP over FIO2 

Humidity

There is no current consensus on HME vs. Heated Wire.  More evidence is supporting HME placement to minimize aerosolization risks.  

• HME:
  • may result in more mucous plugging (be aware of need to instill saline and in-line suction) 
  • Consider over heated-wire particularly with single-limb ventilators (Zhonghua, et. al)
  • Note that some HMEs may claim to be viral filters as well, but most do not 
    
    
• Heated Wire:
  • may result in more condensate in tubing, AVOID breaking circuit to empty condensate (exposure risk), used closed-system trap if available.  
  • may increase risk of aerosolization (heat + humidity)

• May take an extended period of time to wean 
• Vent criteria to consider: FIO2 < 0.4, PEEP < 8-10 on PS < 10 
• Avoid T-Piece Trials (use PS instead) 

Prone Positioning 

• Treat as high-risk (airborne)
• Emphasis is on early proning, even before intubation (as oxygenation worsens)
• Deep Sedation (RASS -4 to -5) should be considered while proning 
• After proning, wait about an hour, then recheck ventilator parameters (Pplat, PEEP, VT) - make changes as necessary (CP)
• Prone for no less than 6-hours at a time (multiple sessions per day), but preferably 12-20 hours/day (JAMA, WHO, SCCM)
• Some recommend d/c prone once patient is sustained in stable state (FIO2 needs, Pplat, ABG, P/F)
  
  
• If patient in prone requires CPR, AHA supports compressions in prone (if intubated)
  
  

Recruitment Maneuvers  

• Yes, consider CPAP 35-40 for 15-40 seconds 
• Do not use incremental PEEP recruitment 
  
  

iNO and Inhaled Prostaglandins

• General advice is to avoid iNO, although there is at least one study testing it right now 
• Consider short trial of inhaled pulmonary vasodilators. If no response, discontinue 

ECMO 

• Consider V-V ECMO when other options have been optimized 

Multiple Patients on a Ventilator   

• Strong recommendation against - see full collaboration for details 

Bronchoscopy

• Avoid bronchoscopy whenever possible, routine use is discouraged due to risk.  
• Consider in-line bronch adapter if necessary 

Suctioning and Bronchial Hygiene 

• Strong preference for closed suctioning only (in-line suction) when intubated
• Do not induce for sputum collection
• Avoid open suction techniques, including nasotracheal suctioning, open suction of the tracheostomy/stoma 
  
• Avoid Bronchial Hygiene Therapies that may increase risk of cough when possible (chest physiotherapy, IPV, etc.) 
  

Aerosolizing drugs/treatments should be considered HIGH RISK *treat as Airborne with N-95 or higher mask,  Use HEPA filters if possible when needed 

All aerosol-generating procedures should be done in negative pressure room if possible. Second best is a portable HEPA-filter in room (SCCM)

Choosing a Drug-Delivery Therapy 

1. Use an MDI (with spacer) when possible. Consider shared cannister protocol to preserve aerosolized drug availability. Use MDI adaptor/HME on vent circuit. 
   
   
2. Consider breath-actuated neb (BAN) with filter, or a breath-actuated vibrating-mesh neb to minimize number of breaths required (for example, if MDI unavailable)
   Specific to: 2.5 mg (0.5 mL) of Albuterol, with no saline and no additional drugs
   
   
3. Use a filtered nebulizer (such as those used with pentamidine, or with HEPA/viral filter placed)
   
   
4. On Vent, consider vibrating mesh neb in-line with extra filter at the expiratory port during treatment (CTS)

CPR

Protected Code Blue 

All CPR activities should be performed using Airborne Precautions and should limit the number of people present AHA

Protected Code Blue

• Take the time to put all appropriate PPE on (Airborne + Contact, check PPE) 
• Attempt to minimize number of people in room (3 is seen as ideal) 
• To minimize exposure risks, some hospitals are performing a single round of CPR, then discontinuing further efforts
• Use mechanical CPR device, if available 

Non-Intubated 

• Assess rhythm, defib if ventricular dysrhythmia 
• Bag-mask with filter, or NRB if not bagging 
• Prioritize need to intubate, pause compressions during intubation 

Intubated 

• Consider Leaving on Vent, but change settings (PC, A/C target of 6 mL, FIO2 1.0, Trig OFF, Set Rate 10/min, PEEP to maximize venous return to heart)
• Defib on vent but keep circuit connected (some drop FIO2 to 0.50 during defib - to avoid fire hazard) 

Proned no airway: attempt to place supine 

Proned Airway: Don't turn supine unless no risk of disconnect of vent, defib pads in A-P position, CPR over T7 and T10 vertebral bodies  

Respiratory/Critical

Drugs

For Respiratory purposes, there is no evidence against inhaled steroids - continue as ordered (COPD, Asthma, etc.) 

For systemic Steroids for Asthma, COPD, may still be appropriate (use smallest dose that causes effect) 

When possible, give MDI with spacer as preferred method (avoid nebulizers when possible)

Avoid all but absolutely necessary transports due to risk

• See Full Collab for details on PPE 
• Routes should be designated and dedicated if possible 
• If intubated, use transport vent with filter if available, if not bag with PEEP valve