HJAR May/Jun 2020

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2020 21 For mechanically ventilated adults with COVID-19 and ARDS, we suggest using a conservative fluid strategy over a liberal fluid strategy. For mechanically ventilated adults with COVID-19 and moderate to severe ARDS, we suggest prone ventilation for 12 to 16 hours, over no prone ventilation. For mechanically ventilated adults with COVID-19 and moderate to severe ARDS: We suggest using, as needed, intermittent boluses of neuromuscular blocking agents (NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation. In the event of persistent ventilator dyssynchrony, the need for ongoing deep seda- tion, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 hours. In mechanically ventilated adults with COVID-19 ARDS, we recommend against the routine use of inhaled nitric oxide. In mechanically ventilated adults with COVID-19, severe ARDS and hypoxemia de- spite optimizing ventilation and other rescue strategies, we suggest a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off. For mechanically ventilated adults with COVID-19 and hypoxemia despite optimiz- ing ventilation, we suggest using recruitment maneuvers, over not using recruitment maneuvers. If recruitment maneuvers are used, we recommend against using staircase (incre- mental PEEP) recruitment maneuvers. In mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, we suggest using veno- venous (VV) ECMO if available, or referring the patient to an ECMO center. Remark: Due to the resource-intensive nature of ECMO, and the need for experienced centers and healthcare workers, and infrastructure, ECMO should only be considered in carefully selectedpatients with COVID-19 and severe ARDS. WEAK WEAK WEAK WEAK WEAK WEAK WEAK WEAK WEAK References 1. Presenti A, Antonelli M. National coordination and experience in Italy. ESICM Webinar 19 March 2020. https://www.esicm.org/webinars/ covid-19-national-coordination-experience-in-italy/ 2. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and outcomes of 21 critically ill patients with CO- VID-19 in Washington State. JAMA Published online March 19, 2020. 3. NeymanG, Irvin CB. A single ventilator for multiple simulated pa- tients to meet disaster surge. Acad Emerg Med 2006:13:1246-1249. 4. Paladino L, Silverberg M, Charcaflieh JG, Eason JK, Wright BJ, Palamidessi N, Arquilla B, Sinert R, Maoach S. Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit. Resuscitation 2008;77(1):121-126. 5. Branson RD, Rubinson L. One ventilator, multiple patients – What the data really supports. Resuscitation 2008;79:171-172.(letter) 6. Branson RD and Rubinson L. A single ventilator for multiple patients: Understanding the multiple limitations. Acad Emerg Med. 2006 Dec;13(12):1352-3.(letter) 7. Branson RD, Blakeman TC, Robinson BR, Johannigman JA. Use of a single ventilator to support 4 patients: laboratory evaluation of a limited concept. Respir Care. 2012 Mar;57(3):399-403. 8. Babic MD, Chatburn RL, Stoller JK. Laboratory evaluation of the Vortran Automatic Resuscitator Model RTM. Respir Care. 2007;52(12):1718–1727. 9. Dickson RP, Hotchkin DL, Lamm WJ, et al. A porcine model for ini- tial surge mechanical ventilator assessment and evaluation of two limited-function ventilators. Crit Care Med. 2011;39(3):527–532. Authored by: Richard D Branson MSc RRT FAARC – Editor in Chief, Respiratory Care; University of Cincinnati Dean R Hess – Editor, Respiratory Care Rich Kallet MSc PhD RRT FAARC – San Francisco General Hospital Lewis Rubinson PhD MD - Chief Medical Officer, Morristown Medical Center, Morristown, NJ