Thread by @srrezaie

Fascinating paper shared with me via @DFarcy Preliminary Observations on the Vent Management of ICU #COVID19

sfar.org/preliminary-ob…

COVID-19 ICU pts are NOT similar to ARDS pts. They have profound hypoxia with pulmonary compliance that is generally high

#COVID19FOAM

High-Pulmonary Compliance: Hypoxic vasoconstriction. Major issue is lung perfusion. Increasing PEEP and prone positioning are of minimal help with recruitment of collapsed lungs. In these patients high PEEP (>15cmH20) may compromise right cardiac filling

Oxygen Alone vs Ventilation: High FiO2 more important in the short run, other interventions (i.e. intubation) may be more harmful than buying time

Management of PEEP: This should be limited at 8 – 10cmH20 as higher levels will not increase pulmonary compliance and will impact venous return and cause more harm. Further increases in PEEP should be monitored with SvO2 and/or echo to assess right heart function

Prone Positioning: Should be considered a rescue maneuver and most likely not beneficial in patients with high compliance

Nitric Oxide: Should be considered to maintain lung perfusion

Microthrombosis and associated ischemic events are common

Liberal Tidal Volume: In high compliance pts, target TV > 8mL/kg (ideal body weight)

Shunt Determination: Shunt fraction is best strategy to assess oxygenation. etCO2/PaCO2 is a useful tool. Ratio <1 sugges elevated shunt & dead space (area of lung ventilated & not perfused)

Bottom Line:

PEEP levels low
TV >6mL/kg
RR <20BPM
Avoid intubation as this is of higher benefit than the costs of intubation