As coronavirus cases surge in the United States with estimates that 5% of COVID-19 patients will need intensive care, US hospitals may quickly consume their limited supply of critical care beds and equipment.
Bill Pruitt, RRT, CPFT, AE-C, FAARC
The sudden appearance of the novel coronavirus disease 2019 (COVID-19) in China and subsequent rapid spread throughout the world has not been seen before in looking back at other pandemics. The coronavirus is easily transmitted person-to-person and once established it can quickly carry a patient from being healthy to being critically-ill, including acute respiratory distress syndrome (ARDS) caused by the viral pneumonia. Younger patients seem to be less affected while older patients and those with comorbid conditions are at greater risk for increased morbidity (having the disease and poor health) and increased mortality.[1-2]
COVID-19 is transmitted by respiratory droplets (as in coughing or sneezing), by body fluids, or by touching contaminated surfaces. Patients can be free from symptoms and still spread the disease. Of the 72,314 cases of COVID-19 cases reported in China by the Chinese Center for Disease Control and Prevention (C-CDC), 81% were classified as mild (having mild or no pneumonia), 14% were classified as severe (having dyspnea, tachypnea >30 BPM, SpO2 < 93%, PaO2/FiO2 < 300, and/or lung infiltrates within 24 to 48 hours), and 5% were classified as critical (having respiratory failure, septic shock, and/or multiple organ dysfunction or failure). From the C-CDC report published in February 2020, death occurred in 2.3% of the confirmed cases of COVID-19, all occurring in the critically-ill classification (no deaths occurred in the mild or severe population).
ICU admission may occur after a gradual decline in health as the median duration from onset of symptoms to going into the ICU is 9 to 10 days and once admitted, ARDS has been diagnosed in two-thirds of the ICU admissions. According to the CDC, most patients confirmed to have COVID-19 have fever and/or cough and difficulty breathing. Healthcare personnel (HCP) should take aggressive measures to protect themselves from exposure to COVID-19, protect transmitting the disease to other patients, and protect against carrying the virus into the community .
Infection Control Measures
CDC recommendations for infection control are clear on the need for proper hand hygiene and use of personal protective equipment (PPE) related to COVID-19. Infection control procedures, if properly followed, protect HCPs, other patients, the community, and protect against contaminating surfaces that could later transmit the virus. Proper hand hygiene is the first, easiest, and most important measure to take in infection control. Hand hygiene includes thorough washing with soap and water for at least 20 seconds before and after patient contact and before and after use of PPE (or use of alcohol-based hand rub containing 60-90% alcohol).
The CDC recommendations state that an N95 respirator masks is needed anytime a procedure is done that would produce an aerosol (ie sputum induction or open-system suctioning) to provide filtered inspired air. N95 masks need to be fit-tested to ensure proper protection. For those with facial hair or other issues that may interfere with using the N95 masks, powered air purifying respirators should be worn.
Eye protection (including goggles or disposable face shield) should be worn to protect against splashes and sprays (eyeglasses and contact lenses are NOT adequate for protection). In times of limited supply, N95 masks and eye protection devices may have to be worn from patient to patient (extended use). Use of clean isolation gowns and clean gloves are recommended and should be replaced between patients.
Patients should be in a single-person room with the door closed and airborne infection isolation rooms (negative pressure rooms) should be reserved for patients having procedures done which generate aerosols. The CDC infection control recommendations also address issues for limited supply of PPE, proper training for donning and removing PPE, alternatives for N95 respirators if supplies are lacking, and policies addressing patient transport, visitors, cleaning, use and storage of equipment, and more.5
Critical Care for COVID-19 Patients
As mentioned earlier, 5% of COVID-19 patients will need intensive care. ICU admissions tend to be older (median age of 60 years) and some 40% have co-morbid conditions including cardiac disease and diabetes. With viral pneumonia and acute hypoxemic respiratory failure, the management of ICU patients with COVID-19 matches the current approach for ARDS, with a few exceptions. Some patients may be successfully managed with the use of high-flow nasal oxygen therapy or noninvasive ventilation; however, there needs to be an awareness of generating an aerosol from the high-flow approach or if the noninvasive masks have leaks that release air into the environment. If either or both of these options are tried but unsuccessful, patient management needs to move to early intubation and initiation of mechanical ventilation.
Lung-protective strategies are the best approach in dealing with COVID-19 patients with consideration for using the proper tidal volume, PEEP levels linking to FiO2 settings, limitation of inspiratory pressures, prone positioning, and possible use of extracorporeal membrane oxygenation (ECMO) if conditions warrant. A minimum distance of six feet should be used to separate patients if single patient private rooms are not available. Intravenous fluids should be managed conservatively and empiric early administration of antibiotics should be used to address possible bacterial pneumonia.
Strict infection control measures are needed as discussed above. Many critically ill patients with COVID-19 develop shock and acute kidney failure; kidney dialysis may need to be provided in addition to the other supportive measures mentioned. Patients may need to have measures in place to evaluate and treat delirium, and counseling regarding death and dying may need consideration. Nutritional support should be provided to support the immune system and reduce stress on the body. With the virus beginning in China, Chinese herbs were used in treatment and there may be research coming out in the future that investigates this aspect of care.
The Cochrane Library has prepared a Special Collection of reviews that evaluate the safety and effectiveness of many of the management issues just mentioned. Using an up-to-date evidence-based approach should help bring about more positive outcomes when dealing with critically ill COVID-19 patients. The special collection on COVID-19 can be found online at Cochrane Library. Patients should be asked about enrolling in clinical trials for researching supportive or targeted therapies.
As the disease spreads rapidly, planning early on is needed at both local and regional levels to handle a surge in critical care resources such as trained and experienced staff, equipment—particularly ventilators, ICU beds, PPE supplies, ECMO, and dialysis machines. The ICU surge can overwhelm a hospital, a city, a region, and even a nation, so proper planning must happen immediately to look for ways to reduce the potential crush of critically-ill patients and deal with the high acuity of large numbers.
Finally, planning needs to be done to handle the possibility of triaging patients in the face of a shortage of ventilators. A proposal published in Chest in 2019 examined this dilemma and gave a reasoned approach on how this might be done. Patients are prioritized based on prognosis for short-term survival (using SOFA for adults/PELOD-2 for pediatrics), prognosis for long-term survival (using assessment of comorbid conditions), with secondary considerations including life-related (life-cycle) status. This gives higher priority to children up to age 49, then 50-69, 70-84, > 85 years of age, and pregnancy. If priority scores are equal, priority moves to some fair, transparent chance of getting mechanical ventilation. This could be first-come, first-served, or a lottery.
We are in the middle of a potential explosion of COVID-19 patients needing intensive care. This pandemic is widespread and moving rapidly. Hospitals and healthcare providers will be challenged in a multitude of issues to meet the need of these patients. Early, appropriate, extensive measures can help blunt the impact of the COVID-19 pandemic and help us prepare for the next.
Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a senior instructor and director of clinical education in the department of Cardiorespiratory Sciences, College of Allied Health Sciences, at the University of South Alabama in Mobile. Bill also spends time helping uninsured adult patients who have pulmonary or sleep issues at Victory Health Partners, a faith-based clinic in Mobile that serves the Gulf coast region.
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24.
- Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. 2020 Mar 11.
- Chang D, Xu H, Rebaza A, Sharma L, Cruz CS. Protecting health-care workers from subclinical coronavirus infection. The Lancet Respiratory Medicine. 2020 Mar 1;8(3):e13.
- From the CDC website on COVID-19 for clinical criteria: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html Accessed 3/17/2020.
- From the CDC website on COVID-19 for infection control: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed 3/17/2020.
- Biddison EL, Faden R, Gwon HS, Mareiniss DP, Regenberg AC, et. al. Too many patients… a framework to guide statewide allocation of scarce mechanical ventilation during disasters. Chest. 2019 Apr 1;155(4):848-54.