CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2020; 07(02): 054-061
DOI: 10.1055/s-0040-1713016
Review Article

Clinical Management of Critical COVID-19 Patients: Insights from the Literature and “On the Field” Experience

Francesco Alessandri*
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
Federico Bilotta*
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
Giancarlo Ceccarelli
2   Department of Public Health and Infectious Diseases, University of Rome Sapienza, Policlinico Umberto I Rome, Rome, Italy
,
Franco Ruberto
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
Fabio Araimo
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
Carmela Imperiale
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
Francesco Pugliese
1   Department of Anesthesia and Intensive Care Medicine, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
,
for the PolU COVID-19 Team › Author Affiliations

Abstract

The recent outbreak of the coronavirus disease (COVID-19) is a health emergency all over the world. Several health care professionals are currently putting their best efforts to deal with this situation. The aim of this review is to report insights from the literature and “on the field” experience in clinical management of critical COVID-19 patients. Respiratory support varies from high flow nasal cannula (HFNC) to noninvasive and invasive mechanical ventilation, often associated with nitric oxide, prone position, and extracorporeal membrane oxygenation (ECMO). Experienced specialists have to manage the airways minimizing any contamination and virus spread. The hemodynamic management of critical COVID-19 patients requires not only an accurate fluid strategy, but also an appropriate use of vasopressors and inotropes. Various adjuvant treatments have been proposed: antiviral drugs, immunomodulators, anticoagulants, antibiotics, and nutrition.

* These two authors contributed equally to the paper.
Group Information: The Policlinico Umberto I COVID-19 (PoLU COVID-19 Team) Members: Pugliese Francesco, MD, Bilotta Federico, MD, Alessandri Francesco, MD, Ruberto Franco, MD, Araimo Fabio, MD, Imperiale Carmela, MD, Albante Alida, MD, Auricchio Daniela, MD, De Lazzaro Francesco, MD, De Lauri Daniela, MD, Di Santo Carmela, MD, Ianni Stefano, MD, Magnanimi Eugenia, MD, Ratini Fabiola, MD, Sabani Anna, MD, Titi Luca, MD, Vaccaro Paola, MD, Giordano Giovanni, MD, Manganelli Chiara, MD, Mancone Massimo, MD, Bruno Katia, MD, Celli Paola, MD, Consolo Stella, MD, Croce Claudia, MD, Giannetti Lorena, MD, Martelli Sabina, MD, Messina Teresa, MD, Pattelli Elisa, MD, Perrella Serena, MD, Piazzolla Mario, MD, Portieri Monica, MD, Ricci Claudia, MD, Almenrader Nicole, MD, Arzilla Roberto, MD, Delia Emilia, MD, Di Giovanni Claudio, MD, Macrì Carlotta, MD, Marandola Maurizio, MD, Nardecchia Giada, MD, Pacilli Massimo, MD, Pacini Francesca, MD, Tordiglione Paolo, MD




Publication History

Article published online:
11 June 2020

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  • References

  • 1 Huang C, Wang Y, Li X. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395 (10223) 497-506
  • 2 Coronavirus COVID-19 outbreak: latest news, information and updates. Available at: https://www.pharmaceutical-technology.com/special-focus/covid-19/coronavirus-covid-19-outbreak-latest-information-news-and-updates/. Accessed April 21, 2020
  • 3 Zhou P, Yang XL, Wang XG. et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; 579 (7798) 270-273
  • 4 Lin L, Lu L, Cao W, Li T. Hypothesis for potential pathogenesis of SARS-CoV-2 infection—a review of immune changes in patients with viral pneumonia. Emerg Microbes Infect 2020; 9 (01) 727-732
  • 5 Yang X, Yu Y, Xu J. et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020; 8 (05) 475-481
  • 6 Munster VJ, Koopmans M, van Doremalen N, van Riel D, de Wit E. A novel coronavirus emerging in China—key questions for impact assessment. N Engl J Med 2020; 382 (08) 692-694
  • 7 Li Q, Guan X, Wu P. et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382 (13) 1199-1207
  • 8 Wang D, Hu B, Hu C. et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020; 323 (11) 1061-1069
  • 9 Chang D, Lin M, Wei L. et al. Epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside Wuhan, China. JAMA 2020; 323 (11) 1092-1093
  • 10 Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. Int J Antimicrob Agents 2020; 55 (03) 105924
  • 11 Mao L, Jin H, Wang M. et al. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020; DOI: 10.1001/jamaneurol.2020.1127.
  • 12 Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence?. Lancet Neurol 2020; 19 (05) 383-384
  • 13 Chung M, Bernheim A, Mei X. et al. CT imaging features of 2019 novel coronavirus (2019-nCoV). Radiology 2020; 295 (01) 202-207
  • 14 Kanne JP. Chest CT findings in 2019 novel coronavirus (2019-nCoV) infections from Wuhan, China: key points for the radiologist. Radiology 2020; 295 (01) 16-17
  • 15 Soldati G, Smargiassi A, Inchingolo R. et al. Is there a role for lung ultrasound during the COVID-19 pandemic?. J Ultrasound Med 2020; DOI: 10.1002/jum.15284.
  • 16 World Health Organization. Clinical management of severe acute respiratory infection (sari) when covid-19 disease is suspected: interim guidance. Available at: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed May 19, 2020
  • 17 Chu DK, Kim LH, Young PJ. et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018; 391 (10131) 1693-1705
  • 18 Festic E, Bansal V, Kor DJ, Gajic O. US Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG–LIPS). SpO2/FiO2 ratio on hospital admission is an indicator of early acute respiratory distress syndrome development among patients at risk. J Intensive Care Med 2015; 30 (04) 209-216
  • 19 Alhazzani W, Møller MH, Arabi YM. et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med 2020; 46 (05) 854-887
  • 20 Frat JP, Thille AW, Mercat A. et al. FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015; 372 (23) 2185-2196
  • 21 Ni YN, Luo J, Yu H, Liu D, Liang BM, Liang ZA. The effect of high-flow nasal cannula in reducing the mortality and the rate of endotracheal intubation when used before mechanical ventilation compared with conventional oxygen therapy and noninvasive positive pressure ventilation. A systematic review and meta-analysis. Am J Emerg Med 2018; 36 (02) 226-233
  • 22 Lyons C, Callaghan M. The use of high-flow nasal oxygen in COVID-19. Anaesthesia 2020; DOI: 10.1111/anae.15073.
  • 23 Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care 2013; 58 (04) 589-596
  • 24 Chandra D, Stamm JA, Taylor B. et al. Outcomes of noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998-2008. Am J Respir Crit Care Med 2012; 185 (02) 152-159
  • 25 Chawla R, Dixit SB, Zirpe KG. et al. ISCCM guidelines for the use of non-invasive ventilation in acute respiratory failure in adult ICUs. Indian J Crit Care Med 2020; 24 (Suppl. 01) S61-S81
  • 26 Lucchini A, Giani M, Isgrò S, Rona R, Foti G. The “helmet bundle” in COVID-19 patients undergoing non invasive ventilation. Intensive Crit Care Nurs 2020; DOI: 10.1016/j.iccn.2020.102859.
  • 27 Yoshida T, Amato MBP, Kavanagh BP, Fujino Y. Impact of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome. Curr Opin Crit Care 2019; 25 (02) 192-198
  • 28 Cheyne WS, Gelinas JC, Eves ND. Hemodynamic effects of incremental lung hyperinflation. Am J Physiol Heart Circ Physiol 2018; 315 (03) H474-H481
  • 29 Alraddadi BM, Qushmaq I, Al-Hameed FM. et al. Saudi Critical Care Trials Group. Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Influenza Other Respir Viruses 2019; 13 (04) 382-390
  • 30 Arabi YM, Arifi AA, Balkhy HH. et al. Clinical course and outcomes of critically ill patients with Middle East respiratory syndrome coronavirus infection. Ann Intern Med 2014; 160 (06) 389-397
  • 31 Meng L, Qiu H, Wan L. et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology 2020; 132 (06) 1317-1332
  • 32 Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. Covid-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med 2020; 201 (10) 1299-1300
  • 33 Walkey AJ, Del Sorbo L, Hodgson CL. et al. Higher PEEP versus lower PEEP strategies for patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 2017; 14 (Suppl. 04) S297-S303
  • 34 Alessandri F, Pugliese F, Ranieri VM. The role of rescue therapies in the treatment of severe ARDS. Respir Care 2018; 63 (01) 92-101
  • 35 Guérin C, Reignier J, Richard JC. et al. PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368 (23) 2159-2168
  • 36 Bloomfield R, Noble DW, Sudlow A. Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev 2015; (11) CD008095
  • 37 Mora-Arteaga JA, Bernal-Ramírez OJ, Rodríguez SJ. The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and metaanalysis. Med Intensiva 2015; 39 (06) 359-372
  • 38 Hong X, Xiong J, Feng Z, Shi Y. Extracorporeal membrane oxygenation (ECMO): does it have a role in the treatment of severe COVID-19?. Int J Infect Dis 2020; 94: 78-80
  • 39 Ramanathan K, Antognini D, Combes A. et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med 2020; 8 (05) 518-526
  • 40 Hariri G, Joffre J, Leblanc G. et al. Narrative review: clinical assessment of peripheral tissue perfusion in septic shock. Ann Intensive Care 2019; 9 (01) 37
  • 41 Fougères E, Teboul JL, Richard C, Osman D, Chemla D, Monnet X. Hemodynamic impact of a positive end-expiratory pressure setting in acute respiratory distress syndrome: importance of the volume status. Crit Care Med 2010; 38 (03) 802-807
  • 42 Wiedemann HP, Wheeler AP, Bernard GR. et al. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354 (24) 2564-2575
  • 43 Silversides JA, Major E, Ferguson AJ. et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med 2017; 43 (02) 155-170
  • 44 Brown SM, Pittman J, Miller Iii RR. et al. Right and left heart failure in severe H1N1 influenza A infection. Eur Respir J 2011; 37 (01) 112-118
  • 45 Paddock CD, Liu L, Denison AM. et al. Myocardial injury and bacterial pneumonia contribute to the pathogenesis of fatal influenza B virus infection. J Infect Dis 2012; 205 (06) 895-905
  • 46 Kwong JC, Schwartz KL, Campitelli MA. et al. Acute myocardial infarction after laboratory-confirmed influenza infection. N Engl J Med 2018; 378 (04) 345-353
  • 47 Wang L, Li X, Chen H. et al. Coronavirus disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol 2020; 51 (05) 343-348
  • 48 Joannidis M, Forni LG, Klein SJ. et al. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2020; 46 (04) 654-672
  • 49 Fanelli V, Fiorentino M, Cantaluppi V. et al. Acute kidney injury in SARS-CoV-2 infected patients. Crit Care 2020; 24 (01) 155
  • 50 Simmons J, Ventetuolo CE. Cardiopulmonary monitoring of shock. Curr Opin Crit Care 2017; 23 (03) 223-231
  • 51 Arabi YM, Fowler R, Hayden FG. Critical care management of adults with community-acquired severe respiratory viral infection. Intensive Care Med 2020; 46 (02) 315-328
  • 52 Cao B, Wang Y, Wen D. et al. A trial of Lopinavir-Ritonavir in adults hospitalized with severe covid-19. N Engl J Med 2020; 382 (19) 1787-1799
  • 53 Grein J, Ohmagari N, Shin D. et al. Compassionate use of Remdesivir for patients with severe covid-19. N Engl J Med 2020; DOI: 10.1056/NEJMoa2007016.
  • 54 Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: a single center experience. J Med Virol 2020; DOI: 10.1002/jmv.25801.
  • 55 Sanmartí R, Ruiz-Esquide V, Bastida C, Soy D. Tocilizumab in the treatment of adult rheumatoid arthritis. Immunotherapy 2018; 10 (06) 447-464
  • 56 Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020; 395 (10223) 473-475
  • 57 Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. HLH Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020; 395 (10229) 1033-1034
  • 58 Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and safety of chloroquine for the treatment of COVID-19. J Crit Care 2020; 57: 279-283
  • 59 Shen C, Wang Z, Zhao F. et al. Treatment of 5 critically ill patients with COVID-19 with convalescent plasma. JAMA 2020; 323 (16) 1582-1589
  • 60 Zhou N, Pan T, Zhang J. et al. Glycopeptide antibiotics potently inhibit cathepsin L in the late endosome/lysosome and block the entry of Ebola virus, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV). J Biol Chem 2016; 291 (17) 9218-9232
  • 61 Bacharier LB, Guilbert TW, Mauger DT. et al. Early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial. JAMA 2015; 314 (19) 2034-2044
  • 62 Gautret P, Lagier JC, Parola P. et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020; DOI: 10.1016/j.ijantimicag.2020.105949.
  • 63 Iba T, Levy JH, Warkentin TE, Thachil J, van der Poll T, Levi M. Scientific and Standardization Committee on DIC, and the Scientific and Standardization Committee on Perioperative and Critical Care of the International Society on Thrombosis and Haemostasis. Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation. J Thromb Haemost 2019; 17 (11) 1989-1994
  • 64 Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost 2020; 18 (05) 1094-1099
  • 65 Kaiying Y, Hanping S. Interpretation of expert recommendations on medical nutrition therapy for patients with new coronavirus pneumonia. Nat Med J China 2020; 100: 724-728
  • 66 Romano L, Bilotta F, Dauri M. et al. Medical nutrition therapy for critically ill patients with covid19. Eur Rev Med Pharmacol Sci 2020; 24 (07) 4035-4039
  • 67 Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA 2020; DOI: 10.1001/jama.2020.4031.