COVID 19 Updates

1. COVID -19
Critical Care Management
Dr Ramprasad Gorai
MBBS. DTCD. MD
Consultant- Pulmonary & Critical Care Medicine
Health World Hospitals , Durgapur.

2. CASE DEFINITION
(As per WHO-China joint commission report)
Suspected case
A patient with Acute respiratory tract infection (sudden onset of at
least one of the following: cough, fever, shortness of breath) AND
with no other aetiology that fully explains the clinical presentation
AND with a history of travel or residence in a country/area
reporting local or community transmission* during the 14 days
prior to symptom onset;
OR
• A patient with any Acute respiratory illness AND having been in
close contact with a confirmed or probable COVID-19 case in the
last 14 days prior to onset of symptoms;
OR
• A patient with Severe acute respiratory infection (fever and at least
one sign/symptom of respiratory disease (e.g., cough, fever,
shortness breath)) AND requiring hospitalisation (SARI) AND with
no other aetiology that fully explains the clinical presentation.

3. Cont..
Probable Case
A suspected case for whom testing for virus causing
COVID-19 is inconclusive (according to the test
results reported by the laboratory) or for whom
testing was positive on a pan-coronavirus assay.
Confirmed Case
A person with laboratory confirmation of virus
causing COVID-19 infection, irrespective of
clinical signs and symptoms

4. Natural History of COVID 19

6. Spectrum of disease severity
• Mild illness was reported in 81% patients
• Severe illness ( Hypoxemia, >50% lung
involvement on imaging within 24 to 48 hours)
in 14%- Pneumonia, Severe Pneumonia
• Critical Disease (Respiratory failure, shock,
multi-organ dysfunction syndrome) was
reported in 5% ARDS, Sepsis, Septic Shock,MI
• Overall case fatality rate was between 2.3 to
5%

7. Pneumonia
• No signs of severe
pneumonia
• No need for supplemental
oxygen
Severe Pneumonia
• Fever or suspected
respiratory infection
Plus
Any one of the following:
1) respiratory rate>30
2) severe respiratory distress
3) SpO2≤ 93% on room air

8. ARDS (Berlin definition)
Onset within 1 week of a known clinical insult or new or worsening
respiratory symptoms
Chest imaging
(CXR / CT / lung USG)
bilateral opacities, not fully explained by volume overload,
lobar or lung collapse or nodules
Origin of pulmonary
infiltrates
Respiratory failure not fully explained by heart failure / fluid
overload. Objective assessment (eg echocardiography) to
exclude hydrostatic oedema, if no risk factor is present
Oxygenation
impairment
Mild ARDS 200 < PaO2 /FiO2 ≤ 300 (with PEEP / CPAP ≥ 5 or nonventilated)
Moderate ARDS 100 < PaO2 /FiO2 ≤ 200 (with PEEP ≥ 5 or non-ventilated)
Severe ARDS PaO2 /FiO2 ≤ 100 (with PEEP ≥ 5 or non-ventilated)
When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS
(including in non-ventilated patients)

9. Sepsis
• life threatening organ dysfunction
caused by a dysregulated host
response to suspected or proven
infection
• Signs of organ dysfunction (SOFA
Score: 0-24):
1) Hypoxemia
2) Coagulopathy (thrombocytopenia)
3) Hyperbilirubinemia
4) Hypotension
5) Altered mental status (GCS)
6) Reduced urine output and / or
↑creatinine
• Sepsis = SOFA ≥ 2 (Assume the
baseline
• score as zero if data are not
available)
Septic Shock
• Sepsis with
• persisting hypotension
despite adequate volume
resuscitation, requiring
vasopressors to maintain
MAP ≥ 65 mmHg and
• serum lactate level > 2
mmol/L

10. Monitor closely for
signs of clinical deterioration
• Rapidly progressive respiratory failure
• Shock
• Sepsis
Monitor vital signs and gas exchange (ABG) at regular intervals
Do not delay intubation if worsening

11. Spectrum of disease severity
AU Wu Z, McGoogan JM SO
JAMA. 2020
81% non severe
14%
severe non
critical
5%
Critical
Mortality
42-
62%
8 %
0.1
%
2-3
%

12. Risk factors and Prognostic Determinants
• Higher body temperature is associated with
more severe disease and higher fatality.
i) Lymphopenia : appeared to be a good
predictor of severe disease and worse
outcomes, a lymphocyte count of less than
2000/cu.mm was associated with poorer
outcomes .
ii) Neutrophil / lymphocyte ratio greater than
2 was associated with higher mortality
iii) LDH > 245 U/L
iv) HS-Cardiac Troponin > 28 ng/ml
v) Prothrombin time > 16 s
vi) Serum ferritin > 300 μg/L
vii) D Dimer
viii) CRP>100 mg/dl
Patients who worsened, had gradual worsening
of these values.
Epidemiological risk factors
• Older Age
• Male sex
• Medical comorbidities
• Chronic pulmonary diseases
• Cardiovascular disease
• Chronic kidney disease
• Diabetes

15. Management Plan

17. Case Fatality
• Case-fatality proportion among cases aged ≥60 years
was:
– 60-69 years: 3.6%
– 70-79 years: 8%
– ≥80 years: 14.8%.
• 0.9% with no underlying medical conditions
• 10.5% for those with cardiovascular disease,
• 7% for diabetes, and
• 6% each for chronic respiratory disease, hypertension,
and cancer

18. Cause of mortality
Qiurong Ruan, ICM 2020

19. Management
COVId-19 + Hypoxia

20. Typical presentations
and features

21. Indian Journal of Critical Care Medicine, https://www.ijccm.org/doi/IJCCM/pdf/10.5005/jp-
journals-10071-23395

23. ARDS- Phenotype
Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different
phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2
Different COVID-19 patterns found at presentation in the emergency department depend on
the interaction between three factors:
1) the Severity of the infection, the Host response, Physiological reserve and
Comorbidities;
2) the Ventilatory responsiveness of the patient to hypoxemia;
3) the Time elapsed between the onset of the disease and the observation in the hospital.
The interaction between these factors leads to the development of a time-related disease
spectrum within two primary “phenotypes”:
Type L, characterized by Low elastance (i.e., high compliance), Low ventilation to perfusion
ratio, Low lung weight and Low recruitability and
Type H, characterized by High elastance, High right-to-left shunt, High lung weight and High
recruitability

24. Type L and Type H patients are best identified by CT scan and are affected by different
pathophysiological mechanisms. If CT not avaialable, defintinon could be used as surrogates:
respiratory system elastance and recruitability.
Understanding the correct pathophysiology is crucial to establishing the basis for
appropriate treatment.

25. Panel A: CT scan acquired during spontaneous breathing. The cumulative distribution of
the CT number is shifted to the left (well aerated compartments), being the 0 to -100 HU
compartment, the nonaerated tissue virtually 0. Indeed, the total lung tissue weight was
1108 g, 7.8% of which was not aerated and the gas volume was 4228 ml. Patient receiving
oxygen with Venturi mask, inspired oxygen fraction of 0.8.

26. Panel B: CT acquired during mechanical ventilation at end-expiratory pressure at 5
cmH2O of PEEP. The cumulative distribution of the CT scan is shifted to the right (non-
aerated compartments) while the left compartments are greatly reduced. Indeed, the total
lung tissue weight was 2744 g, 54% of which was not aerated and the gas volume was 1360
ml. The patient was ventilated in Volume Controlled mode, 7.8 ml/kg of tidal volume,
respiratory rate of 20 breaths per minute, inspired oxygen fraction of 0.7

28. Criteria for ICU Admission
1) Need for mechanical ventilation.
2) Need for vasopressors.
3) Respiratory rate > 25 breaths per minute.
4) PaO2 <50 mm Hg on room air or SpO2 <90% on
supplemental oxygen of 6 Lpm.
5) Confusion.
6) Leukopenia.
7) Thrombocytopenia.
8) Uremia
9) Multilobar infiltrates.
10) Hypotension requiring fluid resuscitation.
11) Hypothermia.
12) quick sequential organ failure assessment (qSOFA) > 2.
Indian Journal of Critical Care Medicine, https://www.ijccm.org/doi/IJCCM/pdf/10.5005/jp-
journals-10071-23395

29. Non Invasive Ventilation

30. NIV
• How to use it?
– BiPAP/ PS + PEEP / CPAP/ Assist
control settings
– Settings
• Fio2: 30- 100% to target Sp02
88-94%%
• PS: 5-20 cm of H20 to target
TV 6-7 ml/kg
• Peep: 5-10 cm H20 to target
Sp02 88-94%
• Inspiratory trigger: 2cm of
H20
• Expiratory trigger: 10-20% of
PIFR
• Avoid positive pressures of >
25 cm of H20
Close monitoring is required

31. • Full PPE with N95 and face shield
• Ensure scene safety & check readiness of all
essential drugs & equipments prior to
intubation
• Most experienced member to intubate
• Complete airway assessment
• Hemodynamic evaluation & optimization, if
needed
• Use HME with bacterial-viral filter in every
oxygenation interface (face mask, circuit, ETT,
catheter mount, LMA)
• Use closed system suctioning
• Preoxygenation with 100% oxygen
• Rapid sequence intubation using induction
agent and muscle relaxant
• Limit bag mask ventilation unless unavoidable
• Cricoid pressure only in case of ongoing
regurgitation
• Use Videolaryngoscope with separate screen,if
available
• In anticipated difficult airway,
anaesthesiologist may be called to intubate
• In unanticipated difficult airway, use LMA and
simultaneously call for expert help
• Clamp ETT during unavoidable disconnections
• Use end-tidal CO2 and CXR to confirm correct
position of ETT
• After intubation, appropriate
cleaning/disinfection of equipment and
environment is mandatory
Airway management

32. Intubatio
n
When ?
Who ?
Where ?
How ?
Scene
safety

33. Intubation
When ?
Who ?
Where ?
How ?
How ?
• Avoid Bag
and mask
ventilation
• RSI
• Use viral
filter

35. Suctioning
• Suctioning
– Close suction only
– As and when required
– Not hourly basis
– PPE precautions if using
open suction

37. Invasive Ventilation

38. Aims of Mechanical Ventilation
• Achieve adequate ventilation - CO2 elimination
• Improve oxygenation
• Relieve respiratory distress - offload respiratory muscles

39. Understanding airway pressures
Respiratory system can be thought of as a mechanical
system consisting of resistive (airways +ET tube) and elastic
(lungs and chest wall) elements in series
Diaphragm
ET Tube
airways
Chest wall
PPL
Pleural pressure
Paw
Airway pressure
Palv
Alveolar pressure
Resistive pressure varies with airflow
and the diameter of ETT and airways.
Flow resistance
The elastic pressure varies with volume and
stiffness of lungs and chest wall.
Pel = Volume x 1/Compliance
Paw = Flow X Resistance + Volume x 1/ComplianceTHUS
Airways + ET tube
(resistive element)
Lungs + Chest wall
(elastic element)
Vivek Iyer MD, MPH Steven Holets,
RRT CCRA AJRCCM

40. Initial Ventilator Setup
Calculate PBW • Males = 50 + 2.3 [height (inches)—60].
• Females = 45.5 + 2.3 [height (inches)—60].
Initial mode Volume Control
(Can use Pressure Control if tidal volume goals are met)
Tidal
volume
Start with 6ml/kg predicted body weight (PBW)
Check Plateau Pressure (Pplat)- (0.5 second inspiratory pause) at
least every 4 hours and after each change in PEEP or VT.
Plateau Pressure goal ≤ 30 cm H2O
If Pplat>30: decrease VT by 1ml/kg steps to minimum 4ml/kg
If breath stacking(auto PEEP) or severe dyspnea occurs,
may increase VT to 7-8 ml/kg if Pplat remains≤30

41. Initial Ventilator Setup
Rate Rate: to match baseline minute ventilation (not > 35)
Set initial rate to approximate baseline minute ventilation (not > 35 bpm). Aim for a pH
over 7.2, do not worry about the PaCO2.If the PaCO2 keeps going up too much in spite of
a respiratory rate (RR) of 35, reduce the dead space in the circuit. If the Ph drops below
7.2, consider adding sodium bicarbonate infusion.
PEEP Higher PEEP (>10) in moderate to severe ARDS
Lower PEEP (≤10) in mild ARDS and “non-ARDS like” severe pneumonia
Continue with higher PEEP if PEEP responsive (recruiters) and lower PEEP if
PEEP non-responsive (non-recruiters)
PEEP responsive (Recruiters): Keeping FiO2 unchanged, usually oxygenation
improves with increase in PEEP with minimal / no drop in mean arterial
pressure, minimal / no rise in PaCO2 and minimal / no rise in driving pressure
Try to keep Pplat ≤30 and driving pressure (Pplat-PEEP)
<15

42. PEEP titration
• In patients with moderate or severe ARDS, higher PEEP instead of
lower PEEP is suggested

43. Check response to initial management
Oxygenation improving
• Reduce PEEP & FiO2
gradually
• Shift to a partial assist
/spontaneous mode,
iftolerated
• Plan for protocolised
liberation from ventilation
Oxygenation not improving
• Search for and address
reasons of failure:
1) Ensure conservative fluid
management
2) Treat patient-ventilator
dyssynchrony, if present
3) Shift mode (volume limited
topressure limited)
4) Search for complications of
disease or ventilation

44. Check response to initial management
Oxygenation improving
• Optimize and persist with
above-mentioned
approaches till patient is
ready for liberation from
ventilation
Oxygenation not improving
• If acceptable gas exchange
not achievable without
incurring Pplat > 30,
consider rescue therapies:
1) Prone ventilation
2) Recruitment maneuvers
3) Neuromuscular blockers
4) Pulmonary vasodilators
5) ECMO

45. Prone Ventilation
Most preferred rescue therapy Consider in
PaO2/FiO2 <150 with a FiO2 ≥0.6 and PEEP ≥5
PaO2/FiO2 ≤100 with a PaO2 ≤60 despite optimization of
ventilator settings at FiO2 of 1
Consider early proning (within first 36 hours)
12-16 hours / day
Always check for contraindications and Complications
(https://www.youtube.com/watch?v=E_6jT9R7WJs)

46. Recruitment maneuvers
• Open the lungs & keep them open :
Recruitment maneuver followed by higher
PEEP
• Consider in PEEP responsive patients
• Preferred method: Sustained high pressure
inflation (35-40 cm H2O of CPAP for 40
seconds)
• Avoid staircase maneuvers (Incremental PEEP)
• Avoid routine use of Recruitment maneuvers

47. Rescue therapies
Neuromuscular
blockers
Consider continuous infusion for up to 48 hrs in case of
persistently high plateau pressures or severe dyssynchrony
Can use intermittent boluses to facilitate lung protective
ventilation, if needed
Pulmonary
vasodilators
If available, a trial of inhaled prostacyclin or nitric oxide
may be considered, if other rescue strategies have failed
ECMO Consider venovenous (VV) ECMO, if available, only in
selected patients with :
1) Refractory hypoxemia (P/F<80), despite optimizing ventilation,
proning and using other rescue therapies
2) Uncompensated hypercapnia (Ph 7.2)
3) Worsening hemodynamic status
Referral to ECMO Centre may be needed

48. • Fresh ventilator circuit for every new patient
• HME with bacterial-viral filters must be fitted
• Tubings and HME with bacterial-viral filters to
be changed every 48 hours / when visibly
soiled
• Use closed system suctioning
• Avoid routine suctioning
• Avoid unnecessary disconnections
• Clamp ETT for unavoidable disconnections
Ventilator precautions

49. Fluid therapy in shock
Strategy of acute
resuscitation
Individualize, monitoring tissue perfusion
Conservative strategy preferred to liberal
Try to avoid hypervolemia
Follow lactate
Choice of fluids Buffered / balanced crystalloids
Avoid HES / Dextran / Gelatin / routine use of albumin
Assess fluid
responsiveness,
Whenever possible
Use dynamic parameters for assessing preload
responsiveness (e.g. Passive Leg Raising), as feasible

50. 1
• First line vasopressor: Noradrenaline
• Vasopressin / Adrenaline if Noradrenaline not
available
2
• Second line vasopressor: Add Vasopressin
3
• Presence of cardiac dysfunction & persistent
hypoperfusion despite fluids & Nordadrenaline:Add
Dobutamine (Avoid Dopamine)
Refractory shock despite fluids & vasopressors: Add IV
Hydrocortisone (200mg / day : continuous infusion /bolus)
Vasoactive agents in shock

51. Supportive Care in ICU
FAST HUGS BID

52. • Feeding & Fluid- Early enteral nutrition (within 24 to 48 hours of admission) if not contraindicated
+ After resuscitation, conservative use of fluids
• Analgesia- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are absolutely
contraindicated
• Sedation-Judicious use of sedation + Daily sedation free intervals, and assessment for weaning
readiness + Deep sedation to prevent premature extubation
• Thromboprophylaxis- Pharmacologic thrombo-prophylaxis, if not contraindicated, should be given.
Mechanical thromboprophylaxis using intermittent pneumatic compression stockings can be used
in cases where pharmacologic thromboprophylaxis is contraindicated
• Head Elevation-Semi-recumbent position if not contraindicated
• Ulcer Prophylaxis- Use of H2 receptor blockers or PPI to prevent gastrointestinal bleeding +
Frequent position change to prevent pressure sores
• Glycemic Control-
• Bowel & Bladder-
• Indwelling Cathter- Optimal care to reduce the incidence of catheter-related blood stream
infections
• Deescalation -

53. Medical
Management

55. Weaning
INTENSIVE CARE SOCIETY NATIONAL GUIDELINES – WHEN AND
HOW TO WEAN

56. Extubation
INTENSIVE CARE SOCIETY NATIONAL GUIDELINES – WHEN AND
HOW TO WEAN

57. Precautions during extubation
– Plan for gentle extubation
– Avoid tracheal suction COVID < 2 weeks duration
at the time of extubation
– In patients with history of less than 2 weeks take
all precautions
– History more than 2 weeks may be treated as non
COVID

58. Discharge Criteria to Step-down Unit or Ward
1) When patient’s physiological status has stabilized and
the need for ICU monitoring and care is no longer
necessary
2) Heart rate < 90/minutes
3) SBP > 120 mm Hg off vasopressors
4) RR < 20/minutes
5) Conscious, oriented
6) Tolerating feeding
7) Not needing any organ support treatment
[continuous renal replacement therapy (CRRT), liver
support, etc.]
Indian Journal of Critical Care Medicine, https://www.ijccm.org/doi/IJCCM/pdf/10.5005/jp-
journals-10071-23395

59. Discharge Criteria for COVID-19 Infected Patients
It is important to ensure that patient is noninfectious at the time of
discharge or at the end of the quarantine. Following criteria can be
used to discharge the COVID-19 infected patients depending upon
whether they are symptomatic or not.
Symptomatic Patients---
• Afebrile for 3 days
• Improved respiratory symptoms
• Nucleic acid tests (rRT-PCR) negative for SARS COV2 from two
consecutive samples of nasopharyngeal or throat swabs at 24 hours’
interval
There should be an interval of 7 days between the first and
final tests before discharge (even if the patient clinically recovers
earlier than 7 days).
Indian Journal of Critical Care Medicine, https://www.ijccm.org/doi/IJCCM/pdf/10.5005/jp-
journals-10071-23395

60. COVID and Cardiac Arrest
• “Crashes” should be avoided by close
monitoring and anticipation, aim for an
elective intubation
• Meaningful outcome in refractory critical
illness and multiple organ failure is <5%:
Assess futility of treatment early
• Conduct in airborne isolation with a minimal
team
• Full PPE with N95 during CPR

62. Everything will be meaningless if…..

63. Aerosol Generating Procedure
• Bag Mask Ventilation
• Intubation
• Suctioning
• Nebulization
• NIV- HFNO/CPAP/BiPAP
• CPR
• Bronchoscopy
• Use Ideal Respirator
• Use Face Shield
• Use PPE
• Use Goggles
• Frequent handwash
• Sanitize regular touch
items
• Less Exposure
• Strengthen Immunity

66. Surgical masks are primarily designed to protect vulnerable patients from medical
professionals.Stopping the wearer from spreading their germs when
coughing/sneezing/speaking.
So they’re designed to protect patients, not to protect the wearer.
There isn’t currently research available on the efficacy of surgical masks (or even
respirators), for protecting wearers against the corona virus

67. N95 vs. FFP3 & FFP2
The most commonly discussed respirator type is N95. This is an American
standard managed by NIOSH – part of the Center for Disease Control (CDC).
Europe uses a “filtering face piece” score (FFP). This comes from EN standard
149:2001 – drafted and maintained by CEN (European Committee for
Standardization).

68. FFP2/FFP3 or N95/N100 are the gold standard
N95 or FFP2 respirator or higher Good breathability with design that
does not collapse against the mouth (e.g. duckbill, cup shaped)

69. Differences between Valve and No valve N95 masks

70. Showing protection against catching infection by different types of masks
Showing reduction in transmission by different types of masks

71. Showing differences between different respirator masks

72. What to look for in an N95 mask ?
The N95 mask should be NIOSH
approved and CE certified.
NIOSH has a website which has a
list of certified licenses holders to
manufacture the N95 mask.
The important thing to identify
is the TC number on the
particular mask.
A genuine N95 respirator mask
should have all the markings
mentioned in Figure 7.

73. Further reading:
1) WHO guidelines
2) GoI & ICMR guidelines
3) CDC guidelines
4) SCCM-ESICM guideline
5) ANZICS guideline
6) NICE guideline
7) ISCCM position statement
8) ESA, RCOA, ASA , ISA recommendations
9) ARDS net guideline
10) SSC guidelines
Thanks