HJAR May/Jun 2020

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2020 19 deliver bronchodilators may be more pru- dent. However, there is no role for inhaled bronchodilators in patients with COVID-19 unless the patent has co-morbid asthma or COPD. Non-ventilated patients Much of the discussion and concern dur- ing this pandemic is associated with me- chanically ventilated patients. It is important to remember that standard oxygen therapy has been indicated in over 75% of hospital- ized subjects. may result in loss of lung recruitment as well as result in unnecessary exposure of the caregivers. The use of inhaled nitric oxide could be given a short trial. We suggest this be a short trial with preestablished criteria for continued used or discontinuation. We also look forward to improved access and reduced costs for this therapy in the midst of this pandemic. Aerosol therapy – nebulizers or pressurized metered dose inhalers Most patients with COVID-19 do not need inhaled bronchodilator therapy. The use of a nebulizer may increase the transfer of particles into the envi- ronment and decrease the life of expira- tory circuit filters. The use of pMDIs to not viable candidates for this illness. Again, the “it’s better than nothing” or “these can be used in the least ill patients” may not apply. The least ill patients do not require intubation. Those that require intubation, require a ventilator capable of meeting the parameters outlined in the ARDSnet treat- ment guidelines. Of note, artificial resuscita- tors are only intended for use as life support when attended one caregiver to one patient. And these devices have been shown to fail without alarm with changes in position. 8 We have similar concerns with the multi- tude of potential DIY (Do it yourself) projects and hack challenges to create a ‘simple’open source ventilator. Mechanical ventilation in this scenario requires a ventilator capable of managing ARDS including PEEP 10-20 cm H2O, VT 300-600 ml and minute vol- ume of 10-15 L/min. Failure to meet these requirements will not allow support of the these critically ill patients. 9 What about an inhaled vasodilator? Inhaled vasodilators should not be used rou- tinely. Aerosolized vasodilators should be avoided. The profound hypoxemia associated with SARS-CoV-2 may respond to an inhaled vasodilator. We agree that routine use of an inhaled vasodilator is not supported or warranted. However, in the absence of a re- sponse to PEEP, lung recruitment, or prone position (or a patient unable to be proned) an inhaled vasodilator might be considered for refractory hypoxemia. The study from Seattle used aerosolized vasodilators in sev- eral patients. 1 Given the mode of transmis- sion of the virus, the use of an aerosolized vasodilator might be unwise. Additionally, the requirement for an expiratory filter to prevent accumulation of aerosol in the ex- piratory valve will require breaking the cir- cuit to change at predetermined intervals. In the current environment, changing filters