Ventilation of COVID-19 patients in intensive care units
Identifieur interne : 000085 ( Pmc/Corpus ); précédent : 000084; suivant : 000086Ventilation of COVID-19 patients in intensive care units
Auteurs : Stefan Möhlenkamp ; Holger ThieleSource :
- Herz [ 0340-9937 ] ; 2020.
Url:
DOI: 10.1007/s00059-020-04923-1
PubMed: 32313971
PubMed Central: 7169372
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Ventilation of COVID-19 patients in intensive care units</title><author><name sortKey="Mohlenkamp, Stefan" sort="Mohlenkamp, Stefan" uniqKey="Mohlenkamp S" first="Stefan" last="Möhlenkamp">Stefan Möhlenkamp</name><affiliation><nlm:aff id="Aff1">Klinik für Kardiologie und Internistische Intensivmedizin, Bethanienkrankenhaus Moers, Bethanienstr. 21, 47441 Moers, Germany</nlm:aff></affiliation></author><author><name sortKey="Thiele, Holger" sort="Thiele, Holger" uniqKey="Thiele H" first="Holger" last="Thiele">Holger Thiele</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.9647.c</institution-id><institution-id institution-id-type="ISNI">0000 0001 2230 9752</institution-id><institution>Universitätsklinik für Kardiologie, Herzzentrum Leipzig,</institution><institution>Universität Leipzig,</institution></institution-wrap>Strümpellstr. 39, 04289 Leipzig, Germany</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32313971</idno><idno type="pmc">7169372</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169372</idno><idno type="RBID">PMC:7169372</idno><idno type="doi">10.1007/s00059-020-04923-1</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000085</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000085</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Ventilation of COVID-19 patients in intensive care units</title><author><name sortKey="Mohlenkamp, Stefan" sort="Mohlenkamp, Stefan" uniqKey="Mohlenkamp S" first="Stefan" last="Möhlenkamp">Stefan Möhlenkamp</name><affiliation><nlm:aff id="Aff1">Klinik für Kardiologie und Internistische Intensivmedizin, Bethanienkrankenhaus Moers, Bethanienstr. 21, 47441 Moers, Germany</nlm:aff></affiliation></author><author><name sortKey="Thiele, Holger" sort="Thiele, Holger" uniqKey="Thiele H" first="Holger" last="Thiele">Holger Thiele</name><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.9647.c</institution-id><institution-id institution-id-type="ISNI">0000 0001 2230 9752</institution-id><institution>Universitätsklinik für Kardiologie, Herzzentrum Leipzig,</institution><institution>Universität Leipzig,</institution></institution-wrap>Strümpellstr. 39, 04289 Leipzig, Germany</nlm:aff></affiliation></author></analytic><series><title level="j">Herz</title><idno type="ISSN">0340-9937</idno><idno type="eISSN">1615-6692</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Phua, J" uniqKey="Phua J">J Phua</name></author><author><name sortKey="Weng, L" uniqKey="Weng L">L Weng</name></author><author><name sortKey="Ling, L" uniqKey="Ling L">L Ling</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Alhazzani, W" uniqKey="Alhazzani W">W Alhazzani</name></author><author><name sortKey="M Ller, Mh" uniqKey="M Ller M">MH Møller</name></author><author><name sortKey="Arabi, Ym" uniqKey="Arabi Y">YM Arabi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gattinoni, L" uniqKey="Gattinoni L">L Gattinoni</name></author><author><name sortKey="Coppola, S" uniqKey="Coppola S">S Coppola</name></author><author><name sortKey="Cressoni, M" uniqKey="Cressoni M">M Cressoni</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gattinoni, L" uniqKey="Gattinoni L">L Gattinoni</name></author><author><name sortKey="Chiumello, D" uniqKey="Chiumello D">D Chiumello</name></author><author><name sortKey="Caironi, P" uniqKey="Caironi P">P Caironi</name></author></analytic></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="letter"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Herz</journal-id><journal-id journal-id-type="iso-abbrev">Herz</journal-id><journal-title-group><journal-title>Herz</journal-title></journal-title-group><issn pub-type="ppub">0340-9937</issn><issn pub-type="epub">1615-6692</issn><publisher><publisher-name>Springer Medizin</publisher-name><publisher-loc>Heidelberg</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32313971</article-id><article-id pub-id-type="pmc">7169372</article-id><article-id pub-id-type="publisher-id">4923</article-id><article-id pub-id-type="doi">10.1007/s00059-020-04923-1</article-id><article-categories><subj-group subj-group-type="heading"><subject>Letters to the Editor</subject></subj-group></article-categories><title-group><article-title>Ventilation of COVID-19 patients in intensive care units</article-title><trans-title-group><trans-title xml:lang="de">Beatmung von COVID-19-Patienten auf Intensivstationen</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Möhlenkamp</surname><given-names>Stefan</given-names></name><address><email>stefan.moehlenkamp@bethanienmoers.de</email></address><xref ref-type="aff" rid="Aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Thiele</surname><given-names>Holger</given-names></name><address><email>holger.thiele@medizin.uni-leipzig.de</email></address><xref ref-type="aff" rid="Aff2">2</xref></contrib><aff id="Aff1"><label>1</label>Klinik für Kardiologie und Internistische Intensivmedizin, Bethanienkrankenhaus Moers, Bethanienstr. 21, 47441 Moers, Germany</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.9647.c</institution-id><institution-id institution-id-type="ISNI">0000 0001 2230 9752</institution-id><institution>Universitätsklinik für Kardiologie, Herzzentrum Leipzig,</institution><institution>Universität Leipzig,</institution></institution-wrap>Strümpellstr. 39, 04289 Leipzig, Germany</aff></contrib-group><pub-date pub-type="epub"><day>20</day><month>4</month><year>2020</year></pub-date><fpage>1</fpage><lpage>3</lpage><history><date date-type="received"><day>13</day><month>4</month><year>2020</year></date><date date-type="rev-recd"><day>14</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>14</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020</copyright-statement><license><license-p>This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.</license-p></license></permissions></article-meta></front><body><p>About 5–15% of patients with COVID(corona virus disease)-19 infection require intensive care surveillance and ventilatory support. Current recommendations suggest early intubation of COVID-19 patients mainly for two reasons: (1) severe hypoxemia with PaO<sub>2</sub>/FiO<sub>2</sub> often <200 mm Hg, fulfilling Berlin criteria of moderate-to-severe acute respiratory distress syndrome (ARDS); and (2) to protect staff from viral transmission [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>]. Mortality during mechanical ventilation appears to be high, however, and lung-protective ventilation is mandatory. Gattinoni et al. reported that many patients with COVID-19 pneumonia are initially characterized by a relatively well-preserved lung compliance despite severe hypoxemia, which is generally not observed in typical ARDS [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR4">4</xref>]. Their concept of “L-type” and “H-type” pneumonia was presented at an ESICM webinar on April 2, 2020 [<xref ref-type="bibr" rid="CR5">5</xref>]. These contributions and current recommendations form the basis of this brief review.</p><p>The proposed COVID-19 pathophysiology is given in more detail elsewhere [<xref ref-type="bibr" rid="CR4">4</xref>]. In brief, viral infection may lead to subpleural inflammation, an increase in vascular permeability, and interstitial oedema. Impaired (regional) vasoreactivity with vasoplegia may counteract hypoxic vasoconstriction and further increase shunt fraction, which can be easily estimated (Fig. <xref rid="Fig1" ref-type="fig">1</xref>, ①). The physiologic response to hypoxemia is increased ventilation with increased tidal volume and an increase in respiratory rate. An increased metabolic drive from inflammation, high fever, and a rise in oxygen consumption and demand further increases respiratory drive and breathing work. Patients need careful surveillance for early detection of deterioration (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,②). Biomarkers are helpful in assessing the clinical trend. Current suggestions reserve the use of high-flow nasal oxygen (HFNO) or noninvasive ventilation (NIV) for mild hypoxemia, with airborne precautions and a low threshold for intubation to avoid viral nosocomial transmission to staff [<xref ref-type="bibr" rid="CR1">1</xref>]. In addition, similar to ventilator-induced lung damage (VILI), stress and strain on the lung associated with noninvasively generated high tidal volumes may also cause patient self-induced lung injury (P-SILI). Unlike ARDS, the majority of COVID-19 lungs are not small and stiff (“baby lung”), but have a near-normal compliance and will likely not benefit from high positive end-expiratory pressure (PEEP). For COVID-19 patients, the precise role of early HFNO or NIV therapy in moderate to severe hypoxemia should be clarified in a clinical trial setting with a special focus on viral transmission to healthcare workers.<fig id="Fig1"><label>Fig. 1</label><caption><p>Illustration of a ventilation strategy for COVID-19 patients. <italic>SpO</italic><sub><italic>2</italic></sub> O<sub>2</sub> saturation, <italic>NIV</italic> noninvasive ventilation, <italic>MV</italic> mechanical ventilation, <italic>PBW</italic> predicted body weight, <italic>pts</italic> patients, <italic>HFNO</italic> high-flow nasal oxygen, <italic>∆P</italic> driving pressure, <italic>RR</italic> respiratory rate, <italic>ETCO</italic><sub><italic>2</italic></sub> end-tidal CO<sub>2</sub>, <italic>V</italic><sub><italic>T</italic></sub> tidal volume, <italic>PEEP</italic> positive end-expiratory pressure, <italic>CRS</italic> compliance of the respiratory system, <italic>kPa</italic> kilopascal (to convert to mm Hg, use factor 7.5), <italic>(vv‑)ECMO</italic> veno-venous extracorporeal membrane oxygenation. (Modified from [<xref ref-type="bibr" rid="CR5">5</xref>]) </p></caption><graphic xlink:href="59_2020_4923_Fig1_HTML" id="d29e273"></graphic></fig></p><p>In worsening hypoxemia, additional end-organ failure, or in the presence of contraindications such as delirium, invasive mechanical ventilation is required. Timely intubation should be carried out by the most skilled operator in a small drilled team, preferably avoiding bag-mask ventilation, using rapid sequence induction, video-laryngoscopy, personal protective equipment, and end-tidal capnometry. Ventilator settings initially with lower PEEP and higher tidal volume than in typical severe ARDS can be adapted with targets as indicated (Fig. <xref rid="Fig1" ref-type="fig">1</xref>, ③④), with a PEEP of 8 cm H<sub>2</sub>O, driving pressure <15 cm H<sub>2</sub>O, and a plateau pressure to achieve tidal volumes of about 8 ml/kg predicted body weight especially in hypercapnic patients to begin with. The PEEP can then be gradually up-titrated to about 15 cm H<sub>2</sub>O as needed (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,⑤), keeping driving pressure (∆P) low. Importantly, ∆P is not simply the difference between PEEP and plateau pressure, but the resulting tidal volume (VT) should be normalized to the respiratory system compliance (CRS), i.e., ∆P = VT/CRS, and hence be adjusted to the size of the aerated lung. Tidal volume too low for the size of the aerated lung may lead to hypoventilation and atelectasis. A low compliance indicates a functional baby lung and usually responds to higher PEEP (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,⑥). By contrast, COVID-19 patients often do not have baby lungs. Instead, they usually benefit from early prone positioning for 16 h or longer depending on the effect, in order to improve ventilation–perfusion (V/Q) mismatch by redistributing pulmonary perfusion (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,⑦). Indeed, the concept of <italic>L‑type</italic> and <italic>H‑type</italic> COVID-19 pneumonia was proposed because many patients initially have <italic>low</italic> elastance (= high compliance), a <italic>limited</italic> PEEP response and <italic>low</italic> recruitability, and a <italic>low</italic> V/Q matching (L-type).</p><p>Some patients may develop “hyperinflammation” and aggravation of pulmonary oedema, partly due to viral infection, bacterial superinfection, VILI or P‑SILI, heart failure, fluid overload, multi-organ dysfunction, or a combination of all of these factors. Worsening inflammation may indicate transition toward the H‑type, characterized by <italic>high</italic> elastance (= low compliance), a <italic>higher</italic> recruitability and PEEP response, and a <italic>high</italic> right-to-left shunt [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR5">5</xref>], i.e. typical ARDS. These patients may benefit from a further stepwise increase in PEEP even beyond 15 cm H<sub>2</sub>O every 15–30 min, or possibly from recruitment maneuvers (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,⑧). Neuromuscular blockade may improve transpulmonary pressure and has an anti-inflammatory effect. Fluids should be restricted depending on cardiac pre-load, with a negative daily balance to reduce pulmonary oedema. Heparin should be given to prevent pulmonary embolism and micro-thrombosis in this presumably pro-thrombotic disease. Other causes of respiratory failure should be repeatedly assessed. Clinical evidence of neurotropic effects of the virus should not be missed. If oxygenation is still inadequate and the patient is deteriorating, vv-ECMO (veno-venous extracorporeal membrane oxygenation) must be considered (Fig. <xref rid="Fig1" ref-type="fig">1</xref>,⑨).</p><p>In summary, ventilation of COVID-19 ICU patients is challenging because of the heterogeneous lung pathology that requires an individualized lung-protective ventilation strategy to improve outcome.</p></body><back><notes notes-type="COI-statement"><title>Conflict of interest</title><p>S. Möhlenkamp and H. Thiele declare that they have no competing interests.</p></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Phua</surname><given-names>J</given-names></name><name><surname>Weng</surname><given-names>L</given-names></name><name><surname>Ling</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations</article-title><source>Lancet Respir Med</source><year>2020</year><pub-id pub-id-type="doi">10.1016/S2213-2600(20)30161-2</pub-id><pub-id pub-id-type="pmid">32272080</pub-id></element-citation></ref><ref id="CR2"><label>2.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Alhazzani</surname><given-names>W</given-names></name><name><surname>Møller</surname><given-names>MH</given-names></name><name><surname>Arabi</surname><given-names>YM</given-names></name><etal></etal></person-group><article-title>Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19)</article-title><source>Intensive Care Med</source><year>2020</year><pub-id pub-id-type="doi">10.1007/s00134-020-06022-5</pub-id><pub-id pub-id-type="pmid">32222812</pub-id></element-citation></ref><ref id="CR3"><label>3.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gattinoni</surname><given-names>L</given-names></name><name><surname>Coppola</surname><given-names>S</given-names></name><name><surname>Cressoni</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Covid-19 does not lead to a “typical” acute respiratory distress syndrome</article-title><source>Am J Respir Crit Care Med</source><year>2020</year><pub-id pub-id-type="doi">10.1164/rccm.202003-0817LE</pub-id><pub-id pub-id-type="pmid">32228035</pub-id></element-citation></ref><ref id="CR4"><label>4.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gattinoni</surname><given-names>L</given-names></name><name><surname>Chiumello</surname><given-names>D</given-names></name><name><surname>Caironi</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>COVID-19 pneumonia: different respiratory treatment for different phenotypes?</article-title><source>Intensive Care Med</source><year>2020</year><pub-id pub-id-type="doi">10.1007/s00134-020-06033-2</pub-id><pub-id pub-id-type="pmid">32291463</pub-id></element-citation></ref><ref id="CR5"><label>5.</label><mixed-citation publication-type="other">Camporota L, Guerin C (2020) How to ventilate in COVID-19. <ext-link ext-link-type="uri" xlink:href="https://esicm-tv.org/webinar1_live_20-how-to-ventilate-in-covid-19.html">https://esicm-tv.org/webinar1_live_20-how-to-ventilate-in-covid-19.html</ext-link> (ESICM-webinar on April 2nd). Accessed: 12 April 2020</mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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