3. Respiratory Clinical Approach This is an overview of strategy after reviewing conversations, emails, discussion boards, current various hospital procedures, social media groups, etc. As you can tell the sources aren't exactly "evidence-base" but more of a common consensus, so use them simply as "food for thought:" Acceptable isn't always Normal. Most are treating at a slightly lower SpO2 than normal, allowing for permissive hypercapnia, etc.



Assess carefully. Not all COVID patients present the same. Treat the individual. Expect oxygenation to be an issue, either due to perfusion or due to ARDS-like process. Be watchful for V/Q issues which are more complicated than just administering O2.



Consider Reasonable Steps to Support Patient Status, Avoid Intubation (unless severe ARDS) Escalate O2 from NC to Venti/NRB mask

Strongly consider self-guided treatments, including Lung Expansion (IS) and Bronchial Hygiene (Acapella, for example)

Consider Noninvasive Support (HFNC, perhaps CPAP/NPPV) as a trial

Consider self-proning

Keep head of bed elevated if not proning, sit out of bed, and mobilize as able

Consider a trial of inhaled pulmonary vasodilators



Assess often. Be watching for telltale signs of sudden deterioration. Patients can appear to improve, then "crash" again.



Intubate when Necessary. There is a decision to be made ... balancing between the risk of premature intubation against the risk of sudden respiratory arrest with a chaotic intubation (

There is a decision to be made ... balancing between the risk of premature intubation against the risk of sudden respiratory arrest with a chaotic intubation ( Berlin et al ). Signs of moderate-to-severe ARDS are unlikely to be turned around noninvasively. Significant comorbidities are an indicator of the need to intubate sooner. Work of breathing is probably a stronger indicator of need to intubate than just evidence of hypoxemia

Tachypnea, on its own, may not be a primary indication for intubation (it is an expected physiological response)

Consider trending: is patient stable or improving (consider observation vs. intubating) or is pt declining over time (favor intubating)

Severe refractory hypoxemia (consider in context of other symptoms)



Ventilate Carefully. Ensure lung protection. Watch driving pressures, recruitability. Strongly consider proning

Use of ARDSnet strategies is most common (monitor Pplat, low VT, higher PEEP)

Determine recruitability (consider R/I ratio, for example)

Monitor driving pressures, maintain under 15



Consider lung recruitability in general



Expect a lengthy vent course as the norm. Extubating too aggressively may simply result in a reintubation. Be sensitive to the patient's "peak of illness." Initially, most advice was against performing tracheostomies, particularly open trachs, but some hospitals are now reporting frequent tracheostomy procedures due to vent days.

5. Personal Protective Equipment See Resources at the bottom of this page on PPE 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

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.

Studies of "viral load" support that greatest risk is closest to the patient, and when performing aerosol-generating-procedures. Patients more ill (ICU, for example) have a higher viral load and are more infectious. Healthcare workers are often exposed to these more infectious patients. Current Published Guidelines CDC; SCCM) Direct Care: Surgical mask, Gown, Gloves, Eye Protection (shield or goggles) for direct-care ( WHO

CDC; SCCM) Aerosol-Producing Procedures: N-95 or above mask, Gown, Gloves, Eye Protection (shield or goggles) ( WHO For ANY aerosol-producing procedure, including much of what respiratory does, only perform absolutely necessary procedures, and then airborne precautions are recommended (including N-95 or above mask), as well as eye protection, gloves, gown, Negative Pressure room is ideal (CDC; WHO; SCCM). Includes from the sources: Manual Resuscitation (bagging)

Noninvasive Ventilation

Intubation/Tracheostomy

Bronchoscopies

CPR efforts (compressions + bagging)

Bronchial Hygiene, including Suctioning

Aerosolized Medications (including Nebulizer Treatments)

Proning a patient

Sputum Induction Note: In the studies reported (see the sources in blue in this section), there is an indication that N-95 masks are safer in all situations, but were not found to be "statistically" so. We recommend protecting yourself from exposure when in doubt, with consideration for equipment availability in higher-risk situations. Protection at Home Some report changing at work, (bring scrubs in a bag, change into scrubs, then at end of shift change into clothes, scrubs back into the bag)

If unable to do this, set up a designated area (preferably outside of the main living area) in your home. Clothes, shoes should be shed there.

Consider spraying work shoes with a disinfectant

Wash clothing separately from all other clothes (consensus is most use normal detergent, dry with heat vs cold tumble)

Some who normally wear business casual or lab coats are switching to scrubs

Most report immediately showering after shedding clothing

12. Troubleshooting Please let us know if there are troubleshooting areas you are facing that aren't listed here yet. Signs/Symptoms Possible Causes Possible Strategies Secretions thick, tar-like

Difficulty weaning despite evidence of resolving illness Reports of thick secretions coating ET tube Consider tube exchange (aerosolization risk)

Consider active heated humidity (aerosolization risk) Low PaO2 or SpO2, otherwise "healthy" looking

(WOB mostly normal, Chest imaging mostly normal, etc.) "Silent or Happy Hypoxia" Avoid injury to the lungs, use noninvasive as bridge HFNC > CPAP or NPPV

Avoid intubating, if possible (read Tobin

Consider (awake) proning Sudden Deterioration on Ventilator Reports of higher incidence of pneumothorax with SARS in general, but may be less with COVID - higher lung compliances ( Wax et al

Reports of patients suddenly deteriorating as they reach so-called "peak" of illness.

Potential asynchrony

Deterioration after respiratory improvement may indicate cardiomyopathy Always check basics: airway placement, airway patent, bronchospasm, V/Q change with recent pt position change, etc.

Suspect and rule out pneumothorax

Suspect and rule out pulmonary embolus

Verify synchrony on ventilator, some reports that sedation requirements can be high, delirium high

Check and correct other indications of high O2 demand (such as fever)

Check for metabolic influences (esp non-anion gap)

Adhere to ARDSnet strategies if meeting definition of ARDS

Strongly consider proning, if not already

Watch for flow starvation, esp if neuro involvement ( Worsham et al

Suspect and treat for co-infections, comorbidity involvement Difficulty in Weaning Underlying illness hasn't "peaked"

Respiratory muscle weakness

ET Tube with thick, dried secretions (see above) May take extended period of time to wean/extubate/liberate

Consider bedside trach (controversial) Air-Trapping

(auto-PEEP) More common when bronchospasm or inadequate exhalation time (such as when set rate is high > 30), I:E ratio is inappropriate (should be 1:3 to 1:4, may need 1:5 with obstructive disorders like COPD or CF) Check flow scalar (does exp flow return to baseline?), I:E ratio (at least 1:3 to 1:4?), then decrease TI (or decrease set rate if TI already short) Consider need for bronchodilator (wheezing, etc.) Consider mode (if APRV/Bilevel, some air-trapping is considered therapeutic, exp flow termination should be about 75% of PEFR)

13. Airway

Clearance Bronchoscopy High-Risk due to potential exposures: priority use of PPE (N-95, Face shield, gown, gloves) - avoid use if possible! Bronchoscopy in COVID+ is relatively contraindicated - use only if upper resp samples are negative and needed for significant clinical management (AABIP, IPC)

Postpone all non-urgent bronchoscopies (AABIP, ACS)

Sputum specimens should be obtained by closed suction with endotracheal tube with COVID sampling preference for lower respiratory tract (SCCM)

If considering: minimize disconnections, use of bronchoscopy adapter on ET tube is recommended

If considering: place mask on patient during bronch if not intubated (minimizes exposure)

Consider suction catheter in patient's mouth to create a local negative pressure ( Ferioli et al)

Use of disposable bronchoscope, if possible

Minimal personnel (only essential people needed to perform bronch)

For all samples sent to lab: be sure to alert lab to COVID-19 status

Standard high-level disinfection for equipment Suctioning and Bronchial Hygiene Strong preference for closed suctioning only (in-line suction) when intubated (WHO, CTS)

minimizes aerosolization exposure, decreases derecruitment of lungs (alveoli collapse) Do not induce for sputum collection (such as use of hypertonic) (AABIP) Avoid open suction techniques, including nasotracheal suctioning, open suction of the tracheostomy/stoma

If absolutely necessary, treat as a critical activity with priority on PPE (N-95 mask or higher level, face shield, gown/gloves). Consider use of self-directed bronchial hygiene, whenever possible (Acapella, for example)

14. Aerosolized

Therapies Use MDI with spacer versus a nebulizer. One study showed active virus 3-hours in air sample after a nebulizer treatment (assuming not in a negative pressure room) (Khoo et al; Munster et. al) ( AARC ) There is no role for inhaled bronchodilators with COVID-19 unless comorbidities



Some recommend SVN treatments may be less risky than initially thought ( BW

Aerosolizing drugs/treatments should be considered HIGH RISK *treat as Airborne with N-95 or higher mask (CMAJ, CP)

(CMAJ, CP) (AHA) 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, Arzu)

) Avoid combining aerosol therapy with airway clearance ( Arzu Choosing a Drug-Delivery Therapy (in recommended order of preference, based on exposure risk, not drug deposition, etc.): Use an MDI (with spacer) when possible. Consider shared cannister protocol to preserve aerosolized drug availability. Use MDI adaptor/HME on vent circuit.



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



Use a filtered nebulizer (such as those used with pentamidine, or with HEPA/viral filter placed), preference for mouth-piece over mask (Arzu)



Consideration for surgical mask over interface if administering by HFNC ( Arzu )



On Vent, consider vibrating mesh neb in-line with extra filter at the expiratory port during treatment (CTS, Arzu)

15. Protected

Code Blue Direct Link to the COVID-19 AHA new Algorithms (pg 14+) 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) (AHA)

(AHA) 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, if pt meets height + weight criteria CPR for Non-Intubated Patients

(may result in aerosolizing the virus, increasing risk) Initially, assess rhythm and defibrillate if ventricular dysrhythmia (AHA)

Many (or most?) are not using bag-valve-mask ventilation to minimize exposure-risk. Consider Intubating more Quickly, some practice compression-only CPR until airway is established (CP) Consider use of a nonrebreather mask , covered also with a surgical mask (AHA)

If decision to use BVM: consider use of a HEPA or Bacterial/Viral Filter in-between bag/mask and ensure a TIGHT seal against face - may require 2-people to do so

Pause chest compressions to intubate - allow for more accurate intubation (less particle spread) (AHA) CPR for Intubated Patients (or with artificial airway) Consider leaving on ventilator during code to keep a closed circuit and make the following changes (per AHA guidelines):

The AHA is supporting a model of asynchronous ventilation - as evidence has been spotty about the benefits of breaths anyway (which is why "compression only" CPR is an approved method of layperson CPR) which has to be balanced with the very real threats of exposure to healthcare workers. In addition, Vent outcomes are poor with COVID, CPR outcomes are even poorer.

Mode: PC, A/C with target of 6 mL/kg IBW (avoid alarms and high pressure within the circuit) FIO2: 1.0 Trigger: OFF Set Rate: 10/min (adults, peds) or 30/min (neo) Consider PEEP to optimize for venous return to heart (maybe 8-10, discussed, not published) If/when ROSC is established, place on appropriate clinical settings





and make the following changes (per AHA guidelines): The AHA is supporting a model of asynchronous ventilation - as evidence has been spotty about the benefits of breaths anyway (which is why "compression only" CPR is an approved method of layperson CPR) which has to be balanced with the very real threats of exposure to healthcare workers. In addition, Vent outcomes are poor with COVID, CPR outcomes are even poorer. Defibrillating on Ventilator Risk: while extremely rare, reports of fires/arcing in the presence of an oxygen-enriched environment Reason to Consider: any disconnect of the airway/vent circuit increases aerosolization risk to those in room Modifications to Consider if Leaving on Vent: Drop O2 below 50% and ensure any exhalation is 30 cm (12 in) away (APSF) Consider pausing the ventilator during defibrillation - extra measure of safety despite closed circuit (APSF) DO NOT disconnect the vent circuit and leave on patient - increases risk (AHA, ECRI)

CPR for Patients who are in Prone Position (AHA) No Airway : attempt to place in supine position for resuscitation

: attempt to place in supine position for resuscitation Artificial Airway : avoid turning the patient to supine unless able to do so without risk of equipment disconnection Place defibrillator pads in the A-P position Provide CPR with pt remaining prone - over T7 and T10 vertebral bodies

: avoid turning the patient to supine unless able to do so without risk of equipment disconnection

16. Respiratory/

Critical Drugs Corticosteroids There has been much discussion around the use of steroids with COVID. There is no current evidence to support avoiding steroids, especially inhaled (patients with Asthma, COPD, etc., should continue to take steroids as prescribed/recommended). Consider avoiding drugs that induce cough whenever possible (mucokinetics such as acetylcysteine, hypertonic salines) Consider careful use with patients with abnormal secretions related to diseases - Cystic Fibrosis, Bronchiectasis, as needed when appropriate PPE is available, negative pressure rooms are preferred If thick secretions, some recommend use of 3% saline (closed-circuit) or possibly guiafensin (by NG/OG) Several studies are looking at iNO as as option (see critical care strategies section). Asthma Exacerbation: Consider use of Albuterol by MDI with spacer initially for exacerbation, every 20 mins x 3 doses. Consider IV mag if needed. Avoid continuous albuterol due to aerosolization risk unless absolutely necessary. Be aware of need for early intubation (CHOP). Systemic steroids should still be considered in severe asthma exacerbations (benefits may outweigh risks) (WHO)

17. Transport Considerations Avoid transport when possible, including limiting away-from-room imaging/procedures to absolutely essential for treatment only Consider early transfer of deteriorating patients to ICU (Liew, et al.)

Medically-essential transport only (CDC)

Inform receiving department of COVID+ patient beforehand (CDC)

Transporting Team should wear PPE (some recommend all everything (Liew, et al. ) ), CDC recommends full PPE while handling the patient, but then only wearing a face mask during transport ( CDC

) , do not transfer on HFNC, NPPV, etc. ( ) ). Cover patient with a clean sheet ( CDC Patient should wear surgical mask if not intubated ( CDC , do not transfer on HFNC, NPPV, etc. ( Liew, et al.

Clean and disinfect all high-touch surfaces, including side rails, headboard, footboard, etc. ( NebraskaMed

Routes should be designated (and dedicated, if possible) between departments to minimize contact with others. If team MUST pass through bystander area, it is advised to have security or someone who can safely clear the area prior to arriving. Any accompanying security should wear masks. ( Liew, et al. ) If intubated: use transport ventilator, if available. If no transport vent available, consider bagging (filters!) with PEEP valve

Liew, et al.