Managing Critically Ill Patients with COVID-19, Acute Respiratory Distress Syndrome

Pharmacological treatments for acute respiratory distress syndrome (ARDS) in patients with coronavirus disease 2019 (COVID-19), as well as nonpharmacological options such as prone positioning, can minimize damage and accelerate recovery, according to a session at the American Society of Health-System Pharmacists (ASHP) 2020 Midyear Clinical Meeting and Exhibition.

ARDS is an inflammatory process causing a loss of aerated lung tissue, said presenter Lauren A. Igneri, PharmD, BCPS, BCCCP, clinical pharmacy specialist at Cooper University Healthcare in Camden, New Jersey. Manifestations can include severe hypoxemia, decreased lung compliance, and increased intrapulmonary shunt. In patients who develop pneumonia associated with COVID-19, Igneri said up to 26% require intensive care unit admission and up to 42% develop ARDS.

Although research on pharmacologic management of COVID-19-associated ARDS is still developing, Igneri outlined several options with recent study findings. Neuromuscular blockade (NMBA), for instance, can reduce ventilator dyssynchrony, minimizing spontaneous ventilation and reducing airway pressure. According to Igneri, the Surviving Sepsis Campaign (SSC) recommended first intermittent boluses followed by continuous infusion for patients who do not respond.

Like many therapeutic options, Igneri said it is vital to consider adverse effects of NMBA, including increased duration of mechanical ventilation, neuromuscular weakness, and neuropathy. With these things in mind, the SSC recommends that continuous infusion of NMBA be limited to 48 hours.

Fluid management strategies in patients with ARDS are also important to consider, with both conservative and liberal strategies. Conservative strategies are the most recommended and include diuresis and colloids. According to Igneri, conservative strategies trend toward a mortality benefit, with a study finding a 1.82-day reduction in duration of mechanical ventilation and a 1.88-day reduction in ICU length of stay when using conservative strategies rather than liberal strategies.

Use of corticosteroids faced significant initial reluctance at the beginning of the COVID-19 pandemic, although Igneri noted that more recent literature has begun recommending its use in some cases. Experts have expressed some concerns that use of corticosteroids could inhibit viral shedding, although a study of 78 patients with COVID-19 who received corticosteroids found similar shedding times compared to patients who did not receive corticosteroids.

Notably, the RECOVERY trial demonstrated a reduced mortality in patients with COVID-19 respiratory failure when using corticosteroids. Based on these findings and recent data, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine guidelines currently recommend corticosteroids in early, moderate to severe disease, within 14 days of onset, according to Igneri.

In addition to these pharmacologic treatments for patients with COVID-19-related ARDS, Igneri discussed the use of prone positioning. Theoretical benefits include decreased ventral alveolar distention and improved elastance of the respiratory system. Igneri said a 2010 meta-analysis of patients with ARDS randomized participants to either prone or supine positioning, and found that in patients with severe disease, there was a 10% absolute mortality reduction among the prone positioning group. Experts recommend between 12 and 16 hours per day of prone positioning for patients with ARDS.

Prone positioning in nonintubated patients has fewer benefits and is more debated, Igneri said. Although a retrospective review of 25 intermediate-care unit patients with respiratory failure found that 19 participants achieved a pulse oximeter reading of 95% or greater, 7 participants required intubation. Based on these findings, Igneri said using prone positioning in non-intubated patients could be a marker for whether these patients should be at a higher level of care or should be considered for intubation.

As the literature continues to develop and experts better understand COVID-19 and related ARDS, Igneri said it will continue being important to rely on well-researched and relied-upon supportive care measures in critically patients. She added that the complexity of the disease offers many opportunities for pharmacists to collaborate with other specialties, such as working with nurses to ensure proper prone positioning technique.

REFERENCE

Igneri L. COVID-19: Care of the Critically Ill Patient: A Focus on the Management of Acute Respiratory Distress Syndrome and Coagulopathy. Presented at: 2020 ASHP Midyear Clinical Meeting and Exhibition; virtual: December 6, 2020.