COVID-19: Management of the intubated adult

INTRODUCTION — Coronavirus disease 2019 (COVID-19) can progress in a subset of patients to acute respiratory distress syndrome (ARDS), which often requires intubation and mechanical ventilation.

This topic discusses the management and prognosis of the intubated patient with COVID-19. Clinical features and respiratory care of the nonintubated patient with COVID-19 and management of the hospitalized adult with COVID-19 are discussed separately. (See "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult" and "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)" and "COVID-19: Management in hospitalized adults".) (Related Pathway(s): COVID-19: Anticoagulation in adults with COVID-19.)

Our approach is, for the most part, in keeping with guidelines that have been issued by numerous societies and organizations including the Society of Critical Care Medicine, the Chinese Thoracic Society, the Australian and New Zealand Intensive Care Society (ANZICS), the World Health Organization and by the United States Centers for Disease Control and Prevention and National Institutes of Health [1-9]. (See "Society guideline links: COVID-19 – Index of guideline topics".)

THE DECISION TO INTUBATE — The timing of intubation for acute respiratory failure in patients with COVID-19 is challenging. The procedure also requires additional infection precautions. These issues are discussed separately. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)".)

VENTILATOR MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME — Most patients who are mechanically ventilated due to COVID-19-related acute respiratory distress syndrome (ARDS) should be managed in accordance with evidence-based ARDS strategies (table 1). Data suggest that patients with COVID-19 associated respiratory failure often require prolonged mechanical ventilation for two weeks or longer. (See "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult", section on 'Length of stay'.)

Low tidal volume ventilation

Initial settings — As for all patients with ARDS, patients with COVID-19-related ARDS who require mechanical ventilation should receive low tidal volume ventilation (LTVV) targeting ≤6 mL/kg predicted body weight (PBW; range 4 to 8 mL/kg PBW (table 2 and table 3)).

●We typically use assist control/volume control mode, with an initial tidal volume of 6 mL/kg PBW and a target plateau pressure (Pplat) ≤30 cm H₂O (table 4).

●We typically apply positive end-expiratory pressure (PEEP) according to the strategy outlined in the table (table 4). Since the COVID-19 ARDS phenotype is typically one of severe hypoxemia, we and other clinicians have a low threshold to start with a higher level of PEEP (eg, 10 to 15 cm H₂O) and use PEEP levels at the higher end of the range for the fraction of inspired oxygen (FiO₂), although this strategy is of unproven efficacy [10].

This approach is supported by several randomized trials and meta-analyses that have reported improved mortality from LTVV in patients with non-COVID-19-related ARDS. Expert experience thus far is that this approach is also beneficial in the COVID-19 ARDS population. A multicenter study of mechanically ventilated patients with COVID-19 in the Netherlands demonstrated widespread use of lung-protective ventilation with low tidal volumes, low driving pressure, and high PEEP [11]. One retrospective Italian cohort of COVID-19 patients reported that the median level of PEEP was 14 cm H₂O (interquartile range [IQR] 12 to 16 cm H₂O) [12]; 90 percent of patients required an FiO₂ >0.5, and the median arterial oxygen tension (PaO₂)/FiO₂ ratio was 160 (IQR 114 to 220). Additional details on LTVV in ARDS are provided separately. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Low tidal volume ventilation: Initial settings'.)

Assessing response — The response to LTVV should be assessed within the first four hours of ventilation. We typically reexamine the patient and the ventilator, so compliance can be calculated and synchrony assessed, and we also obtain an arterial blood gas so that the PaO₂:FiO₂ ratio can be measured.

●For those who respond well (eg, FiO₂ <0.6, PaO₂:FiO₂ ≥150 mmHg), we continue LTVV (table 4).

●For those who do not respond to this approach and progress to moderate or severe ARDS (eg, FiO₂ >0.6, PaO₂:FiO₂ <150 mmHg), we continue LTVV but in the prone position, if feasible. This is discussed further elsewhere. (See 'Failure of low tidal volume ventilation' below and "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Patients who are not improving or deteriorating'.)

In our experience, a sizeable proportion of patients have high oxygen requirements and, as such, require LTVV in the prone position, although a small proportion do well supine.

Failure of low tidal volume ventilation

Low tidal volume ventilation in the prone position — For patients with COVID-19 who fail to achieve adequate oxygenation with LTVV, we agree with other experts that providing LTVV in the prone position is the preferred next step to improve oxygenation. Institutions that are not proficient in pronation should educate staff in advance of applying the procedure. The process is similar to that in patients with non-COVID-19-related ARDS. (See "Prone ventilation for adult patients with acute respiratory distress syndrome".)

Criteria — Failure of LTVV is poorly defined but may include any one or more of the following:

•PaO₂:FiO₂ ratio <150 mmHg (some experts use a higher PaO₂:FiO₂ ratio, given the good response seen in this population)

•FiO₂ requirement ≥0.6

•Requirement for PEEP ≥5 cm H₂O

Procedure — The timing, duration, application, contraindications, complications, and discontinuation of prone positioning are similar to that in patients with non-COVID-19-related ARDS. (See "Prone ventilation for adult patients with acute respiratory distress syndrome".)

●Timing of initiation – There is no agreed upon time after initial application of LTVV that prone positioning should be optimally implemented. In general, similar to non-COVID-19 patients, it is thought that implementation of pronation is more likely to be beneficial in the earlier phases of ARDS (eg, first 4 to 12 hours). Should deterioration in oxygenation occur in the later phases of ARDS, the benefits are less clear. (See "Prone ventilation for adult patients with acute respiratory distress syndrome", section on 'Timing of initiation'.)

●Duration of each prone session, application, and contraindications – Similar to non-COVID-19 patients, we typically promote ventilating patients prone for as long as is feasible within a 24 hour period (ie, 12 to 16 hours prone per day). Pronation is repeated daily until it is no longer needed or there is no response, as detailed below (discontinuing pronation). When a patient who is in the prone position shows improvement, FiO₂ and PEEP may be weaned.

Individual intensive care units (ICUs) should coordinate proning and supination at times of best staff availability to facilitate safety for the patient being proned and bystander patients sharing bedside staff. This video, which describes the proning procedure, is freely available. Additional details regarding the contraindications (eg, facial fractures, spinal instability, sternotomy) (table 5) and application (table 6) of prone ventilation are provided separately. (See "Prone ventilation for adult patients with acute respiratory distress syndrome", section on 'Prone procedure'.)

●Discontinuing pronation – Optimal timing and criteria for discontinuing daily prone ventilation is unclear and should be determined on an individualized basis. We use criteria similar to that in studies that have shown benefit in non-COVID-19-related ARDS [13]. As examples pronation may be discontinued if any one of the following is observed:

•Patients have a PaO₂:FiO₂ ratio ≥150 mmHg, FiO₂ ≤0.6, and PEEP ≤10 cm H₂O that are maintained for at least four hours after the end of the last prone session. Some clinicians opt to compare PaO₂, PEEP, and FiO₂ at the end of a prone session and four hours after supination, although the ideal timing of comparison is unclear.

•Patients have no response to pronation. We consider response to be a sustained improvement in gas exchange (eg, >10 mmHg PaO₂ on stable ventilator settings) or evidence of alveolar recruitment (eg, increase in lung compliance based on a fall in plateau pressure for a given tidal volume) during pronation.

●Complications – Prone positioning for selected eligible patients in non-COVID-19-related ARDS appears safe. Complications in COVID-19 patients appear similar to those in non-COVID-19 patients, although the prolonged amount of time that patients with COVID-19 spend prone may increase the risk of certain complications, including ophthalmologic complications and anterior skin breakdown (table 5) [14,15]. (See "Prone ventilation for adult patients with acute respiratory distress syndrome", section on 'Complications'.)

Efficacy — Our preference for using prone ventilation is based on its known efficacy in patients with non-COVID-19-related ARDS, where it has been shown to improve both oxygenation and mortality. Limited data exist in COVID-19 patients [16-21].

●Anecdotal observations of intensivists in the field and limited data in critically ill COVID-19 patients also suggest that, unlike patients who had severe acute respiratory syndrome (SARS), patients with COVID-19-related ARDS respond well to this maneuver [16-18].

●One retrospective study of over 2000 patients with COVID-19 reported a possible reduction in mortality when patients were proned early (ie, within two days) compared with patients who were not proned [19]. A smaller retrospective study reported similar results [17].

●Another retrospective study of 125 patients with COVID-related ARDS who underwent prone positioning reported an improvement in the PaO₂/FiO₂ by 19 percent during proning, higher in those with ARDS (PaO₂/FiO₂ <100; 27 percent) [20].

Subsequent measures — Rescue strategies for patients in whom LTVV and prone positioning fails (see 'Criteria' above) include the following:

●Other ventilatory strategies – In patients with severe hypoxemia who are PEEP responsive, recruitment maneuvers and high PEEP strategies (table 7) may be performed on a trial basis [7]; data supporting their use in non-COVID-19-related ARDS are mixed and described separately. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Ventilator strategies to maximize alveolar recruitment'.)

Airway pressure release ventilation (APRV) has limited impact [22,23]. A systematic review of seven, mostly retrospective, studies reported that APRV improved oxygenation but did not impact mortality or ventilator-free days [22].

●Neuromuscular blocking agents (NMBAs) – We reserve NMBAs for patients with refractory hypoxemia or ventilator dyssynchrony. We do not favor their routine use in any patient with ARDS since data on outcomes are conflicting. (See "Neuromuscular blocking agents in critically ill patients: Use, agent selection, administration, and adverse effects" and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Paralysis (neuromuscular blockade)'.)

●Pulmonary vasodilators – Pulmonary vasodilators may improve ventilation-perfusion mismatch in patients with severe hypoxemia (eg, PaO₂:FiO₂ <100) and may be especially helpful in those with decompensated or acute pulmonary arterial hypertension and right heart dysfunction [7]. However, pulmonary vasodilators only improve oxygenation and do not improve mortality in all-cause ARDS or COVID-related ARDS [24,25]. Importantly, in a patient whose PaO₂:FiO₂ ratio meets proning criteria but numerically improves with initiation of pulmonary vasodilators, prone positioning should not be withheld. (See "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Inhaled pulmonary vasodilators'.)

The two most commonly used agents are inhaled nitric oxide gas (iNO) and aerosolized epoprostenol, which are administered by continuous inhalation. After initiating iNO or epoprostenol, response (eg, 10 percent reduction in FiO₂ requirement) is typically noted within a few hours. The choice of agent is typically institution-dependent and based on local expertise and cost. While some centers use a single agent, other centers use an initial trial of iNO (eg, 30 parts per million [PPM] for one hour) to determine responsiveness; responders are continued on iNO or transitioned to inhaled epoprostenol. iNO may also be preferred since it is associated with a less frequent need to change filters with resultant reduction in the risk to the respiratory healthcare provider.

Inhaled vasodilators should only be administered through a closed system and require skilled personnel for their use. Potential risks and challenges with COVID-19 patients include aerosolization and clogging of bacterial/viral filters used in ventilator circuits, particularly with epoprostenol. Further details regarding their use are described separately. (See "Inhaled nitric oxide in adults: Biology and indications for use", section on 'Acute hypoxemic respiratory failure' and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Inhaled nitric oxide' and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Inhaled prostaglandins'.)

Data to support their use in COVID-19 ARDS are limited [25-32]. These reports have been single-center experiences with small numbers of patients, and long-term outcomes were not evaluated. In one of the larger studies, two-thirds of patients given iNO had improved oxygenation, defined by a >20 percent increase in the partial pressure of arterial oxygen PaO₂:FiO₂ ratio [29]. However, the response was variable and some studies suggested that patients with COVID-19-related ARDS may be less likely to respond compared with patients who had non-COVID-related ARDS [27]. None of the studies demonstrated a mortality benefit.

●Extracorporeal membrane oxygenation (ECMO) – While the World Health Organization suggests ECMO as an early rescue strategy, we only use it in those who fail prone ventilation and the other evidence-based medical strategies listed above. In addition, ECMO is not universally available. As many hospitals choose to cohort patients in COVID-19-only ICUs, there may also be the challenge of delivering ECMO in ICUs that do not routinely care for ECMO patients; this would require the recruitment of additional specialized nursing and perfusionist staff. Of note, ECMO can reduce the lymphocyte count and raise the interleukin-6 level, thereby interfering with the interpretation of these laboratory results [33]. (See "Extracorporeal life support in adults in the intensive care unit: Overview" and "COVID-19: Extracorporeal membrane oxygenation (ECMO)".)

Use of rescue strategies has varied among centers. Among 66 mechanically ventilated patients with COVID-19 in Boston, Massachusetts, 31 (47 percent) underwent prone positioning, 18 (27 percent) were treated with inhaled vasodilator, and 3 (5 percent) received ECMO [34]. In contrast, a single-center retrospective cohort of 52 critically ill patients with COVID-19 in Wuhan, China, reported that 12 percent received prone ventilation and 12 percent received ECMO [35]. Use of ECMO is widely variable and ranges from 1 to 24 percent likely reflecting differences in availability and local practice [12,34-36].

Oxygenation targets — We believe that oxygenation goals in critically ill patients with COVID-19 should be similar to those recommended by ARDSNet (ie, peripheral oxygen saturation between 88 and 96 percent). Special attention should be paid to using peripheral arterial oxygen saturation (SpO₂) targets in patients with darkly pigmented skin, given data which suggest that pulse oximetry may be more likely to overestimate arterial blood oxygen levels in these patients compared with light-skinned patients, potentially leading to occult hypoxemia [37]. Thus, in patients with darkly pigmented skin, we correlate the SpO₂ value with a saturation value derived from an arterial blood gas to ensure accuracy of the SpO₂ measurement; repeat correlation checks may be indicated throughout the patient’s course. (See "Pulse oximetry", section on 'Skin pigmentation'.)

Data that discuss oxygenation goals in non-COVID-19 patients and spontaneously breathing patients are provided separately:

●(See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Positive end-expiratory pressure (PEEP), fraction of inspired oxygen, oxygenation target'.)

●(See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Fraction of inspired oxygen'.)

●(See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Oxygenation targets'.)

Additional COVID-19-specific ventilator equipment precautions — For patients with COVID-19 who have an endotracheal tube (ETT) or tracheostomy and remain on infection control precautions, we perform the following to minimize aerosolization of the virus (table 8):

●Maintain tight seals for all ventilator circuitry and equipment. In addition, it is particularly important to adhere to the standard practice of maintaining the ETT cuff pressure between 20 and 30 cm H₂O so that a tight seal exists between the cuff and the tracheal wall. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Maintain optimal cuff pressure'.)

●Avoid unnecessary disconnection with the ETT or tracheostomy. For example, in-line suction devices and in-line adapters for bronchoscopy are preferred, if resources allow. If disconnection is necessary (eg, during transfer when portable ventilators are used or manual bagging), the ETT or tracheostomy should be temporarily clamped during disconnection and unclamped after reconnection, provided the patient is not spontaneously breathing. This is considered an aerosolizing procedure in which case an airborne infection isolation room is preferable.

●Use dual limb ventilator circuitry with filters placed at the exhalation outlets as well as heat moisture exchange (HME) systems rather than heated humification of single limb circuits. HME should be placed between the exhalation port and the ETT (figure 1 and figure 2). (See "The ventilator circuit".)

●Use appropriate filters and filter change schedule. The ventilator should be wiped down after every filter change.

●Ventilate patients in an airborne isolation room. This is ideal if resources allow, but not necessary since the risk of aerosolization is low with a closed circuit [38]. An airborne isolation room is, however, preferred when aerosol generating procedures take place (eg, extubation, bronchoscopy).

As additional precautions for staff, some experts place intravenous (IV) line monitors and the ventilator outside the room, when feasible (eg, through a wall port) [39,40]. This allows frequent IV medication and ventilator adjustments while simultaneously decreasing the risk of exposure to staff; although, such options may not be feasible in some centers. One study reported a reduction in the number of room entries by nursing from an average of 15 to 8 entries per 12 hour shift following IV pump relocation to outside the room without an increase in the rate of IV extravasation or central line-relation bacteremia, hyperglycemia, or hypotension [39]. The impact on COVID-19 infection rates among staff was not measured.

Determining when COVID-19 infection control precautions in hospitalized patients can be discontinued is discussed in detail elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Discontinuation of precautions'.)

Ventilator alternatives — While not recommended as a first-line strategy, during periods of high demand for ventilation, strategies that employed the use of operating room ventilators were used at some institutions. Limitation and practical application of such a strategy is provided separately. (See "COVID-19: Intensive care ventilation with anesthesia machines".)

MINIMIZING TRANSMISSION RISK WITH INTERVENTIONS — Ventilated patients require frequent evaluation and intervention for complications. Details relevant to patients with COVID-19 are included in this section and mostly relate to infectious precautions while performing these interventions.

Studies that inform infectious risk associated with interventions performed on mechanically ventilated patients with COVID-19 are limited. SARS-CoV-2 RNA has been detected in different clinical specimens to varying degrees. In one study of 1070 specimens obtained from 205 patients with COVID-19, bronchoalveolar lavage fluid specimens showed the highest positive rates (93 percent), followed by sputum (72 percent), nasal swabs (63 percent), fibrobronchoscope brush biopsy (46 percent), pharyngeal swabs (32 percent), feces (29 percent), and blood (1 percent) [41]. No urine specimens tested positive. However, detection of viral RNA does not necessarily indicate that the specimen is infectious.

Risk of infection during airway management is discussed separately. (See "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)'.)

Collection of respiratory specimens in the intubated patient — Some intubated patients require upper or lower respiratory tract sampling for diagnostic purposes (eg, diagnosis of COVID-19, secondary bacterial pneumonia, or ventilator-associated pneumonia [VAP]). These include naso- and oropharyngeal swabs and tracheal aspirates. Tracheal aspirates are ideally collected using closed-circuit, in-line suctioning. In addition, airborne isolation conditions are not always necessary for naso- and oropharyngeal swabs. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

It is rare that lower respiratory tract samples need to be taken for the diagnosis of COVID-19. However, if necessary, we agree with the Society of Critical Care Medicine who recommend obtaining endotracheal aspirates rather than bronchoalveolar lavage via bronchoscopy.

Nonbronchoscopic alveolar lavage ("mini-BAL") may also be performed as an alternative to bronchoscopy, although experience in this procedure is not universal among ICUs. If mini-BAL is performed for the diagnosis of COVID-19, use of smaller aliquots of lavage fluid is prudent (eg, three 10 mL aliquots to obtain 2 to 3 mL of fluid). (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Invasive respiratory sampling'.)

Use of bronchoscopy for the acquisition of lower respiratory tract sampling is discussed below (eg, for VAP). (See 'Bronchoscopy' below.)

Bronchoscopy — Bronchoscopy is an aerosol-generating procedure and should only be performed when necessary and likely to change management. For example, bronchoscopy is reasonable in immunosuppressed patients with respiratory failure of unclear etiology, suspected Pneumocystis jirovecii, suspected foreign body, severe hypoxemia from mucus-plugging-induced lobar collapse, or life-threatening hemoptysis. Bronchoscopy should have a limited role for the diagnosis of COVID-19 and should only be performed for this indication when upper respiratory samples are negative (ie, nasopharyngeal and oropharyngeal swabs, or tracheal aspirates) and the suspicion remains high. If bronchoscopy is needed for the diagnosis of COVID-19, we suggest the instillation of only small aliquots (eg, one to two 10 mL aliquots) to obtain a total of 2 to 3 mL of lavage fluid.

In patients with COVID-19, bronchoscopy should be performed in an airborne infection isolation room, although bronchoscopy through an established airway (eg, endotracheal tube [ETT]) likely carries less risk than bronchoscopy in a spontaneously breathing patient. Full airborne precautions and personal protective equipment (PPE) should be used. Clamping suction tubing or turning off suction after the sample has been obtained before disconnecting the sample from the device is also prudent. Specimens should be in a double zip-locked sealed plastic bag, handled with the usual precautions, and labelled clearly as "COVID-19." (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

We prefer the use of disposable bronchoscopes, although these are not universally available. For nondisposable equipment, we recommend cleaning the suction channels with standard cleaning solutions typically used for highly infectious material. We also suggest covering or sealing any vessel containing the bronchoscope during transport after use and wiping down the transport cart and bronchoscope display tower before leaving the room. Wipe down solution should be hydrogen peroxide or equivalent and should be left wet on all surfaces for at least one minute.

Data to support this practice are limited. One single-center series from Barcelona, Spain, described their experience in performing bronchoscopy on mechanically ventilated patients with COVID-19 [42]. Bronchoscopy was performed in both the supine and prone position and the most common indication was suspected superinfection. Notable was the presence of significant secretions and bronchial plugs that were difficult to suction. Approximately one-third had a new organism identified including Pseudomonas, Staphylococcus, Klebsiella, and occasionally fungal species, similar to typical micro-organisms identified in patients with ventilator-associated pneumonia. No significant complications were reported. However, one bronchoscopist out of a total of three became infected with SARS-CoV-2. In another series, similar results were found except no bronchoscopists became infected, and a protocol that favored use of neuromuscular blockade was used [15]. We recommend a sedation strategy for bronchoscopy that balances the goals of minimizing both total sedation used and patient coughing.

Cardiopulmonary resuscitation — In the event of a cardiac arrest, cardiopulmonary resuscitation (CPR) should proceed with all members of the team wearing appropriate PPE and with only essential personnel in the room. A facility-specific protocol is helpful for both efficacy and staff safety. Bag-mask ventilation should be avoided (if feasible); if available, the ventilator can be used instead to deliver a respiratory rate of 10 breaths per minute. Guidance for advanced cardiac life support and CPR in patients who are prone and cannot be returned to the supine position is provided separately. (See "Advanced cardiac life support (ACLS) in adults" and "COVID-19: Arrhythmias and conduction system disease" and "COVID-19: Arrhythmias and conduction system disease", section on 'Patients requiring cardiopulmonary resuscitation (CPR)' and "Adult basic life support (BLS) for health care providers".)

Other interventions — Guidance is lacking regarding other procedures commonly performed in the intensive care unit (ICU). Many intubated patients have routine indications for central venous and arterial access for monitoring and for vasoactive drug infusion. Grouping standard procedures such as central venous catheter and arterial lines immediately following intubation is appropriate to minimize the frequency of exposure.

In general, emergently indicated procedures and interventions as well as testing should be performed as indicated, with appropriate infectious precautions.

Transfer of COVID-19 patients should be limited to necessary trips (eg, imaging for a diagnosis that would change management, travel to an airborne isolation room for high-risk aerosol-generating procedures such as intubation and extubation).

EXTUBATION AND WEANING — Because extubation is frequently associated with some coughing and expectoration of secretions, it is considered an aerosol-generating procedure. For patients who remain on infection control precautions for COVID-19 at the time of extubation (table 8), we encourage the use of extubation protocols and check lists specific to each institution for reducing risk to healthcare workers. The procedure for palliative extubation should be similar from an infection control standpoint.

Extubation data are uncommon in this population. In one retrospective study, up to one-third of extubated patients with COVID-19 required reintubation, which was associated with a higher mortality [43]. Older age, paralytics, need for high positive end-expiratory pressure prior to extubation, need for greater respiratory support following extubation, and nonpulmonary organ failure predicted reintubation.

Weaning — Readiness for extubation should follow standard practice of performing spontaneous breathing trials (SBT). (See "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults", section on 'Daily spontaneous breathing trials (SBTs)'.)

However, for those who remain on infection control precautions for COVID-19, COVID-specific modifications include the following:

●Equipment – We suggest using closed systems and not using a T-piece trial for SBTs.

●SBTs – To reduce the risk of reintubation following extubation, we prefer a higher degree of readiness for extubation in patients with COVID-19. Practice varies and may include higher criteria for passing an SBT. For example, some experts use lower pressure support ventilation (PSV) parameters (eg, 0 to 5 cm H₂O) rather than the typical higher PEEP to overcome endotracheal tube resistance during the trial, while others promote SBT for longer periods (eg, two to four hours rather than the typical two hours). The rationale for altered criteria is based upon the observation that patients with COVID-19 are intubated for longer periods than non-COVID-19 patients [12] and anecdotal evidence that suggests a high volume of secretions and airway edema; all of these factors place the patient at high risk of postextubation respiratory failure requiring reintubation. (See "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults", section on 'Daily spontaneous breathing trials (SBTs)' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

●Cuff leak test (CLT) – Whether the CLT should be performed routinely prior to extubation is unclear. Performing CLT may be warranted if there is suspicion for upper airway edema (eg, fluid overload) or the patient is at risk for post extubation stridor (eg, prolonged intubation ≥6 days, age >80 years, large endotracheal tube, traumatic intubation). However, it should be weighed against the potential risk of aerosolization, and similar to extubation, it should be preferentially done in an airborne isolation room. Some institutions routinely administer glucocorticoids (eg, methylprednisolone 20 mg intravenously every four hours for a total of four doses if not already receiving dexamethasone) to patients with COVID-19 before extubation and only extubate those in whom the CLT is positive; however practice is variable even among contributors of this topic. (See "Extubation management in the adult intensive care unit", section on 'Cuff leak'.)

Extubation procedure — For patients who remain on infection control precautions for COVID-19, we prefer to perform extubation in an airborne isolation room. Respiratory therapists and others in the room during extubation should adhere to airborne precautions including N95 masks with eye protection or equivalent. In general, only two people are needed, and extra staff outside the room should be available to help with additional equipment. We advocate close communication with a clinician who is experienced in intubation when a patient with COVID-19 is being extubated, particularly for patients predesignated as having a difficult airway, in case rapid reintubation is needed.

While we do not premedicate patients prior to extubation with antitussives, some experts promote their use (eg, lidocaine via endotracheal tube [ETT], low-dose opioid bolus, dexmedetomidine, remifentanil), although data to support this practice are absent.

We typically drape the patient’s chest and face with a plastic cover to provide barrier protection between the patient and the operator (eg, a plastic poncho). Immediately prior to extubation, we set the ventilator in standby mode (or switch off). After balloon deflation, extra care should be taken during ETT removal to keep the inline suction catheter engaged during cuff deflation and to have another handheld suction catheter available for the removal of pharyngeal and oral sections. The ETT should be removed as smoothly as is feasible during inspiration, and immediately disposed of into a biohazard plastic bag bundled together with the ventilator tubing, the plastic drape, tape/ETT holders, and inline suction catheter. The bag is sealed and disposed of immediately.

Further details regarding extubation are provided separately. (See "Extubation management in the adult intensive care unit", section on 'Extubation equipment and technique'.)

Precautions for extubation in the operating room are provided separately. (See "Extubation following anesthesia", section on 'Airway management for patients with COVID-19'.)

Postextubation care — Both low-flow and high-flow oxygen systems should be set up and readily available for postextubation oxygenation. We use supplemental oxygen at the lowest fraction of inspired oxygen (FiO₂) needed. We do not routinely extubate to noninvasive ventilation. Some experts extubate directly to high-flow oxygen via nasal cannulae, although this practice is variable and there are no data to support it. (See "Extubation management in the adult intensive care unit", section on 'Postextubation management'.)

Postextubation oxygenation targets are similar to preintubation targets, which are discussed separately. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Oxygenation targets'.)

TRACHEOSTOMY — Some patients with COVID-19 require tracheostomy (in our experience, <10 percent of ICU admissions) [44-48].

●Indications – Indications appear to be similar to non-COVID-19 patients (eg, failure to wean, failed extubation, secretion management, airway edema, inability to protect airway [eg, poor mental status]). (See "Tracheostomy: Rationale, indications, and contraindications", section on 'Rationale for tracheostomy versus endotracheal tube'.)

●Timing – The optimal timing for tracheostomy in COVID-19 patients is unclear but often deferred beyond 10 days of intubation (eg, 14 to 21 days or longer), although practice varies [48]. Some data suggest that tracheostomy leads to a reduction in sedative use in this population [49]. Data informing timing in this population are limited and discussed separately. (See "Tracheostomy: Rationale, indications, and contraindications".)

●Procedure – For those who remain infectious at the time, tracheostomy is considered a high-risk procedure for aerosolization. Further details are provided separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'COVID-19'.)

●Prolonged weaning – Tracheostomy weaning trials and management of the recovering patient with COVID-19 are discussed separately. (See "COVID-19: Evaluation and management of adults with persistent symptoms following acute illness ("Long COVID")".)

Further details regarding tracheostomy including contraindications, complications, and decannulation techniques are provided separately. (See "Tracheostomy: Rationale, indications, and contraindications" and "Tracheostomy in adults: Techniques and intraoperative complications" and "Tracheostomy: Postoperative care, maintenance, and complications in adults".)

SUPPORTIVE CARE

Routine measures — The supportive care of mechanically ventilated patients that also applies to patients with COVID-19 is provided in several linked topics (see "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Supportive care'). However, potential differences pertinent to COVID-19 patients are discussed in this section.

Venous thromboembolism prevention — In patients with COVID-19, routine pharmacologic venous thromboembolism (VTE) prophylaxis is warranted, preferably with low molecular weight heparin (eg, enoxaparin 40 mg subcutaneously once daily), unless there is a contraindication (eg, bleeding, severe thrombocytopenia). For patients with a creatinine clearance <30 mL/minute, enoxaparin should be reduced to 30 mg daily or changed to unfractionated heparin depending on the severity of kidney impairment and patient weight. Fondaparinux is appropriate in those with heparin-induced thrombocytopenia. (See "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".) (Related Pathway(s): COVID-19: Anticoagulation in adults with COVID-19.)

Decisions regarding full-dose anticoagulation are discussed separately. (See "COVID-19: Hypercoagulability", section on 'Inpatient VTE prophylaxis'.)

Sedation and analgesia — Requirements for and/or use of sedation and analgesia appear to be high in mechanically ventilated patients with COVID-19 [50], and we have observed that heavy use of sedatives and analgesic medication may often be required for ventilator synchrony.

Suitable targets include the following:

●For most patients who are mechanically ventilated with COVID-19, we typically target a Richmond Agitation-Sedation Scale (RASS (table 9)) of -1 to -2 (or similar on a different scoring system).

●For patients with ventilator dyssynchrony despite advanced ventilator adjustments, we target a RASS of -2 to -3.

●For patients with severe dyssynchrony and those requiring neuromuscular blockade, we target a RASS of -4 to -5.

Selection of a sedation and analgesia strategy for COVID-19 patients is similar to that for non-COVID-19 intubated patients with a preference for bolus-dose opioids; for patients who need more sedation we typically administer continuous infusion opioids and then add propofol if increased sedation and analgesia is indicated. We use lowest effective doses and avoid benzodiazepines if possible. Shortages of sedatives may influence the choice of agent.

For patients at risk of harm, such as self-extubation, who remain under infectious precautions, deeper sedation may be necessary because response time to the bedside may be slower, but it should still be minimized.

Further details regarding indications, daily awakening, protocols, and dosing are provided separately. (See "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal" and "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects" and "Pain control in the critically ill adult patient".)

Others — Other supportive measures, mostly discussed in the linked topics below, include the following:

●Nutritional support – The same principles of nutrition used in non-COVID-19 critically ill patients should be applied to critically ill COVID-19 patients [51,52]. We are not proponents of extra protein supplementation, vitamin C or D supplementation, or trace element supplementation over and above the usual recommended daily doses. One retrospective study reported that compared with non-COVID patients, critically ill patients with COVID-19 may have a lower negative energy balance by day 10 of ICU admission, even though enteral nutrition was started earlier in those with COVID-19 [53]. (See "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription" and "Nutrition support in intubated critically ill adult patients: Enteral nutrition" and "Nutrition support in intubated critically ill adult patients: Parenteral nutrition".)

●Fluid and electrolyte management – Unless patients have sepsis or volume depletion from high fever or gastrointestinal losses, we prefer conservative fluid management with buffered or nonbuffered crystalloids typical of that advised for patients with acute respiratory distress syndrome (ARDS); renal function should be monitored carefully. (See "Treatment of severe hypovolemia or hypovolemic shock in adults" and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Conservative fluid management' and "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Intravenous fluids (first three hours)'.)

●Glucose control – (See "Glycemic control in critically ill adult and pediatric patients".)

●Stress ulcer prophylaxis – (See "Stress ulcers in the intensive care unit: Diagnosis, management, and prevention" and "Management of stress ulcers".)

●Hemodynamic monitoring – (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults" and "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults" and "Novel tools for hemodynamic monitoring in critically ill patients with shock".)

●Fever management – (See "Fever in the intensive care unit", section on 'Outcomes'.)

●Early physical therapy – (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation" and "Post-intensive care syndrome (PICS): Treatment and prognosis", section on 'Early ambulation/physical therapy'.)

●Ventilator-associated pneumonia precautions – (See "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults".)

●Strongyloides prophylaxis – (See "COVID-19: Management in hospitalized adults", section on 'Dexamethasone and other glucocorticoids'.)

Use of glucocorticoids for non-COVID-19 reasons — We use low-dose dexamethasone (6 mg daily for 10 days or until discharge) in patients with COVID-19-related acute respiratory distress syndrome (ARDS) who require oxygen supplementation or mechanical ventilation based on evidence that glucocorticoids reduce mortality in such patients. It is unknown whether a higher dosing strategy (eg, dexamethasone 20 mg intravenously [IV] once daily for five days, and then 10 mg once daily for five days) that is used in patients with moderate to severe non-COVID-19-related ARDS who have failed standard therapies (eg, patients with a partial arterial pressure of oxygen/fraction of inspired oxygen [PaO₂:FiO₂] <200 mmHg) would be of additional benefit or harm compared with the dose of dexamethasone advised for COVID-19. (See "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Glucocorticoids'.)

Some intensive care unit (ICU) patients with COVID-19 may have a separate indication for glucocorticoids other than COVID-19. In some of these patients, it may be reasonable to tailor glucocorticoid use to the predominant indication such as the following:

●Asthma exacerbation (see "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Systemic glucocorticoids')

●Eosinophilic pneumonia (see "Idiopathic acute eosinophilic pneumonia", section on 'Treatment')

●Chronic obstructive pulmonary disease exacerbation (see "COPD exacerbations: Management", section on 'Glucocorticoids in moderate to severe exacerbations')

●Adrenal insufficiency (see "Treatment of adrenal insufficiency in adults", section on 'Adrenal crisis')

●Rheumatic disease (see "Overview of the management and prognosis of systemic lupus erythematosus in adults", section on 'Escalation of therapy based on disease activity and severity')

While low-dose glucocorticoids (eg, hydrocortisone 200 to 400 mg/day in divided doses) are indicated for selected patients with septic shock that is refractory to fluid resuscitation [6], no additional hydrocortisone is needed for patients who are receiving dexamethasone for COVID-19 related respiratory failure. The use of glucocorticoids in septic shock is discussed separately. (See "Glucocorticoid therapy in septic shock in adults", section on 'Administration'.)

The use of glucocorticoids for patients who fail a cuff leak test is also discussed separately. (See 'Extubation and weaning' above and "Extubation management in the adult intensive care unit", section on 'Cuff leak'.)

Monitoring for complications — Critically ill patients with COVID-19 should be followed routinely for the development of complications associated with critical illness from COVID-19 or extrapulmonary manifestations of SARS-CoV-2 infection.

●We typically perform daily laboratory studies including complete blood count with differential and routine chemistries. Other laboratory studies are done when clinically indicated including arterial blood gases, liver function studies, and coagulation studies. If cardiac injury is suspected, we measure cardiac troponins and have a low threshold to perform transthoracic echocardiogram. While some experts perform "COVID-19" laboratory studies such as ferritin, C-reactive protein, lactate dehydrogenase, D-dimer, and occasionally interleukin-6, there is no guidance on when to perform these studies and how to make decisions based upon them, which has led to variable practice. Each institution should develop their own protocols regarding the acquisition and interpretation of "COVID-19" laboratory studies. (See "COVID-19: Management in hospitalized adults", section on 'Evaluation'.)

●We do not perform daily chest radiographs in mechanically ventilated patients with or without COVID-19. We perform chest radiography when there is an indication (eg, catheter- or endotracheal tube [ETT]-placement, suspected barotrauma, suspected pneumonia, hemoptysis, or respiratory distress or other clinical change). Chest computed tomography and other imaging including echocardiography and bedside ultrasonography should be limited to those in whom testing would change management. This rationale is based upon the increased risk to others with procedures that require transfer out of the ICU. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Reassessment of position'.)

Common complications in critically ill patients include the following (see "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult", section on 'Complications'):

●Acute kidney injury (see "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension")

●Delirium and other neurologic issues (see "COVID-19: Neurologic complications and management of neurologic conditions")

●Mild transaminitis and other gastrointestinal issues (see "COVID-19: Gastrointestinal symptoms and complications")

●Cardiac injury (eg, myocardial infarction, cardiomyopathy, pericarditis, arrhythmias, cardiac arrest) (see "COVID-19: Cardiac manifestations in adults")

●Thrombosis (see "COVID-19: Hypercoagulability" and "COVID-19: Acute limb ischemia")

●Superinfection, sepsis, shock, multiorgan failure (eg, from ventilator-associated pneumonia [VAP], bloodstream infections, catheter associated infection, strongyloides reactivation) (see "COVID-19: Clinical features", section on 'Acute course and complications' and "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult", section on 'Sepsis, shock, multi-organ failure, secondary infections')

●Barotrauma (see "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult", section on 'Pneumothorax and barotrauma')

Vasopressors — Many patients require vasopressors for hypotension which is often sedation-related but may be due to other conditions including sepsis, either due to primary SARS-CoV-2 infection or a concomitant bacterial infection. The management of patients who present with septic shock due to COVID-19 is similar to that in patients with septic shock from other causes. (See "Evaluation and management of suspected sepsis and septic shock in adults".)

Limiting nebulized medication — Nebulization is considered an aerosol-generating procedure. For patients with COVID-19 who are intubated and require bronchodilators for an evidence-based indication (eg, acute bronchospasm from asthma or chronic obstructive lung disease exacerbation), we prefer the use of in-line metered dose inhalers (MDIs; ie, pressurized inhalers) rather than administration via a standard jet or vibrating mesh nebulizer due to the lower risk of aerosolization associated with MDIs. Data to support this practice are provided separately. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Nebulized medications' and "Delivery of inhaled medication in adults", section on 'Infection control'.)

For medications that can only be administered via the inhaled route, consideration should be given to stopping the medication, if it is not essential for acute care, or using an MDI alternative, if available on formulary. Consideration should be given to the patient using their own supply if MDIs are not on formulary.

Placement of a filter at the expiratory port of the ventilation circuit during nebulization, if not already present, is prudent to minimize aerosolization into the room. Ideally, patients who require nebulizers, should be in an airborne infection isolation room. Only the healthcare staff necessary for nebulizer administration (eg, respiratory therapists or nurse) should be in the room for the initiation of the procedure and airborne precautions should be taken. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Management of coinfections, comorbidities, medication interaction — Critically ill patients with COVID-19 who are intubated are at risk for developing VAP and other infections typical of all critically ill and/or intubated patients (eg, central line or urinary tract infections, fungal infections [54]). The possibility of strongyloides reactivation in the context of glucocorticoid administration should be considered in patients from endemic regions. (See "Strongyloidiasis".)

When treating coinfections, potential drug interactions should be assessed.

Infectious disease experts should be involved early in the management of COVID-19 patients who are critically ill.

Further details regarding management of chronic medications including nonsteroidal anti-inflammatories and angiotensin receptor inhibitors are provided separately. (See "COVID-19: Management in hospitalized adults", section on 'NSAID use' and "COVID-19: Management in hospitalized adults", section on 'Managing chronic medications'.)

COVID-19-SPECIFIC THERAPY — COVID-19-specific therapy, including glucocorticoids, other immunomodulators, and antivirals (algorithm 1), is discussed separately. (See "COVID-19: Management in hospitalized adults", section on 'COVID-19-specific therapy'.)

DISCONTINUING PRECAUTIONS — In general, we discontinue precautions using a nontest (ie, time)-based strategy as outlined in the table (table 8). (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Symptom- and time-based strategies'.)

SPECIAL POPULATIONS — The management of specific populations of patients with COVID-19 include the following:

●Pregnant females – There are no unique recommendations for pregnant females who are critically ill with COVID-19. Pregnancy is not necessarily a contraindication to prone positioning. Issues regarding transmission and risk of acquiring SARS-CoV-2 in pregnant females is described separately. (See "Critical illness during pregnancy and the peripartum period" and "Acute respiratory failure during pregnancy and the peripartum period" and "COVID-19: Overview of pregnancy issues" and "COVID-19: Clinical features", section on 'Pregnant and breastfeeding women'.)

●Sickle cell disease – In patients with sickle cell disease who are critically ill with COVID-19 in whom acute chest syndrome is contributing to their illness, consideration of early exchange transfusions and surveillance for the development of acute pulmonary hypertension is prudent [55]. (See "Acute chest syndrome (ACS) in sickle cell disease (adults and children)", section on 'COVID-19'.)

●Issues that arise for other populations are provided in the following links:

•Renal issues (see "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension")

•Cardiac issues (see "COVID-19: Myocardial infarction and other coronary artery disease issues" and "COVID-19: Arrhythmias and conduction system disease" and "COVID-19: Evaluation and management of cardiac disease in adults")

•Airway management and operating room issues (see "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)')

•Cancer care

•Skin care (see "COVID-19: Cutaneous manifestations and issues related to dermatologic care")

•Rheumatologic diseases (see "COVID-19: Care of adult patients with systemic rheumatic disease")

•Pediatric issues (see "COVID-19: Management in children")

END-OF-LIFE ISSUES — Like any critical illness, severe illness due to COVID-19 carries the potential of significant psychosocial distress to patients, families, and surrogates. In addition, unique aspects of COVID-19 and its management portend greater trauma including anxiety and stigma surrounding a novel pathogen and high-level isolation precautions including visitation limitation or prohibition including at the end of life. High levels of patient, family, and surrogate psychosocial distress should be anticipated and combatted with clear communication strategies and early palliative care involvement (table 10). Even if in-person visitation is not allowed due to public health care concerns, hospitals should promote internet-based visual communication such as video communication between clinicians, families, and isolated patients.

Discussing end-of-life wishes with patients and their family should occur early in the course of management, including before or at hospital admission, especially in light of the poor outcomes for elderly patients with comorbidities who develop acute respiratory distress syndrome (ARDS) and require mechanical ventilation [56]. Consultation with the palliative care teams should also be done to assist families in decision-making and assist clinicians with contentious issues or disagreement that may arise.

Due to the unique aspects of addressing needs of the patient and their caregivers during the COVID-19 pandemic, several online resources are available for clinicians to use when having COVID-19 specific discussions. They provide helpful language and strategies for conversations about a range of issues including, but not limited to, triage decisions, goals of care, resource allocation, and grieving including. These include:

●VIITALtalk

●Center to Advance Palliative Care

●National Coalition for Hospice and Palliative Care

Further principles regarding ethical issues in the intensive care unit (ICU) and advance care planning are discussed separately:

●(See "Palliative care: Issues in the intensive care unit in adults" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Advance care planning and advance directives", section on 'COVID-19 resources'.)

●(See "Ethics in the intensive care unit: Informed consent".)

●(See "Withholding and withdrawing ventilatory support in adults in the intensive care unit".)

●(See "Communication in the ICU: Holding a meeting with families and caregivers".)

●(See "Palliative care: Issues in the intensive care unit in adults" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Advance care planning and advance directives", section on 'COVID-19 resources'.)

●(See "Palliative care: Issues in the intensive care unit in adults" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Advance care planning and advance directives", section on 'COVID-19 resources'.)

SURGE CAPACITY AND RESOURCE ALLOCATION — COVID-19 is a global pandemic and has placed significant increases in demand for acute and critical care services on hospitals in many regions. This has necessitated operations maneuvers to increase capacity to be able to provide care for more patients, for higher acuity patients requiring intensive care unit (ICU) admission and mechanical ventilation, and for patients with special isolation requirements. It is essential that all hospitals and health systems develop task forces to manage patients admitted with this disorder. This involves, but is not limited to, designating COVID-19 ICU bed capacity and care teams, creating back up and expanded staffing schedules, utilizing detailed protocols for infection prevention and medical management, accessing research trials for patients with COVID-19, ensuring adequate personal protection equipment (PPE) supplies and training, forecasting demand, and prioritizing diagnostic lab testing.

Surge capacity may be achieved by maximizing resources across three domains:

●Care spaces (ie, beds)

●Staff

●Physical equipment

In the COVID-19 pandemic, this has included expanding ICU care into non-ICU spaces, utilizing non-critical care trained staff to participate in delivering critical care, and innovative approaches to obtain, conserve, and increase the efficiency of physical equipment including PPE (eg, extended and reuse of N95 masks) and mechanical ventilators (eg, repurposing operating room ventilators). (See "COVID-19: Intensive care ventilation with anesthesia machines".)

In some instances, such as in Italy, despite mobilizing to surge capacity, demand for care still outpaced supply such that overt rationing occurred [57]. All hospitals facing the potential of an acute surge event due to COVID-19 or another insult should have a process to approach the allocation of scarce resources such as ICU beds and mechanical ventilators [58,59]. Most individual states in the United States have guidance documents which can be adapted for local institutions [58]. General principles that guide and underpin scarce resource allocation policies include:

●Maximization of lives saved and/or life-years saved

●Transparency

●Stakeholder and public input

●Separation between the clinical team and the allocation process (eg, triage committees)

●Robust palliative care and supportive measures for all patients especially those who are not provided with critical care resources

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (See "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)".)

SUMMARY AND RECOMMENDATIONS

●Ventilator management strategy – COVID-19 can progress in a subset of patients to acute respiratory distress syndrome (ARDS), which often requires intubation and mechanical ventilation (table 1).

•We use lung-protective, low tidal volume ventilation (LTVV) targeting ≤6 mL/kg predicted body weight (PBW; range 4 to 8 mL/kg PBW (table 2 and table 3)) that targets a plateau pressure ≤30 cm H₂O and applies positive end-expiratory pressure (PEEP) according to the strategy outlined in the table (table 4). We assess the response within the first four hours of ventilation using clinical evaluation and arterial blood gas analysis. For those who respond well (eg, fraction of inspired oxygen [FiO₂] <0.6, arterial oxygen tension [PaO₂]:FiO₂ ratio ≥150 mmHg), we continue LTVV alone. The approach in COVID-19-related ARDS is similar to that in non-COVID-19-related ARDS, which is discussed separately. (See 'Ventilator management of acute respiratory distress syndrome' above and "Acute respiratory distress syndrome: Ventilator management strategies for adults".)

•For patients who have any of the following on LTVV, we suggest continuation of LTVV in the prone position (table 6 and table 5) (Grade 2B) (see 'Failure of low tidal volume ventilation' above):

-PaO₂:FiO₂ ratio <150 mmHg (some experts use a higher PaO₂:FiO₂ ratio, given the good response seen in this population)

-FiO₂ requirement ≥0.6

-Requirement for PEEP ≥5 cm H₂O

This approach is based upon indirect data suggesting a benefit for non-COVID-19-related ARDS and observational data in the COVID-19 population that suggest a similar response. (See "Prone ventilation for adult patients with acute respiratory distress syndrome" and 'Low tidal volume ventilation in the prone position' above.)

•For patients in whom LTVV in the prone position fails or is not suitable, rescue strategies include recruitment maneuvers, high PEEP, neuromuscular blocking agents, pulmonary vasodilators, and extracorporeal membrane oxygenation. (See 'Additional COVID-19-specific ventilator equipment precautions' above and "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Refractory patients'.)

•Oxygenation goals should be similar to those recommended by ARDSNet (ie, peripheral oxygen saturation between 88 and 96 percent). Pulse oximetry may be more likely to overestimate arterial oxygenation in patients with darkly pigmented skin and should be interpreted accordingly. Oxygenation targets in ARDS are discussed separately. (See 'Oxygenation targets' above and "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Positive end-expiratory pressure (PEEP), fraction of inspired oxygen, oxygenation target'.)

●Interventions and precautions – Several procedures, including the collection of respiratory specimens, bronchoscopy, and cardiopulmonary resuscitation are aerosol-generating and should be used only when indicated. All procedures should be grouped, if feasible, and performed in an airborne isolation room with full precautions. Maintenance of tight seals, avoiding unnecessary disconnection, use of dual limb circuitry, appropriate filters (especially on the exhalation circuit), and scheduled "wipe-down" of the ventilator are additional infection control approaches. (See 'Minimizing transmission risk with interventions' above and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and 'Additional COVID-19-specific ventilator equipment precautions' above.)

●Extubation, weaning, tracheostomy – Extubation and tracheostomy are potentially aerosol-generating. We encourage the COVID-19-specific protocols and checklists at each institution. For example, for patients who remain on infection control precautions (table 8), we advocate using closed loop systems for spontaneous breathing trials and performing extubation and tracheostomy in an airborne isolation room. (See 'Extubation and weaning' above and 'Tracheostomy' above.)

●Supportive care – Supportive care and monitoring of intubated patients with COVID-19 are largely the same as for ARDS in general. Prophylaxis of venous thromboembolism is discussed in detail elsewhere. (See 'Supportive care' above and "Acute respiratory distress syndrome: Fluid management, pharmacotherapy, and supportive care in adults", section on 'Supportive care' and "COVID-19: Hypercoagulability", section on 'Inpatient VTE prophylaxis'.)

●COVID-19-specific therapy – This is discussed separately. (See "COVID-19: Management in hospitalized adults", section on 'COVID-19-specific therapy'.)

●End-of-life issues – A greater level of anxiety and trauma among patients and families should be anticipated and combatted with clear communication strategies and early palliative care involvement (table 10). The following resources and links may be helpful. (See 'End-of-life issues' above and "Withholding and withdrawing ventilatory support in adults in the intensive care unit" and "Communication in the ICU: Holding a meeting with families and caregivers" and "Palliative care: Issues in the intensive care unit in adults" and "Advance care planning and advance directives", section on 'COVID-19 resources'.)