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Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19.
Respiration. 2020; 99(6):521-542.R

Abstract

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order.

Authors+Show Affiliations

Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg, Germany. Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf, Germany. Krankenhaus Barmherzige Brüder, Klinik für Pneumologie und konservative Intensivmedizin, Regensburg, Germany.Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Krankenanstalt Bochum, Bochum, Germany.Schwerpunkt Pneumologie, Allergologie, Klinische Immunologie, Zentrum für Schlaf- und Beatmungsmedizin, Krankenhaus Bethanien, Moers, Germany.Institut für Pneumologie an der Universität zu Köln, Cologne, Germany. Klinik für Pneumologie, Krankenhaus Bethanien, Solingen, Germany.Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring GmbH, Berlin, Germany, torsten.bauer@helios-gesundheit.de.Medizinische Klinik IV: Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Klinikum Vest GmbH, Paracelsus-Klinik, Marl, Germany.Fachkrankenhaus Kloster Grafschaft GmbH, Akademisches Lehrkrankenhaus der Philipps-Universität Marburg, Schmallenberg, Germany.Klinik für Pneumologie, Lungenklinik Hemer, Hemer, Germany. Universität Witten-Herdecke, Witten, Germany.Universität Witten-Herdecke, Witten, Germany. Klinik für Pneumologie, Klinikum Köln-Merheim, Kliniken der Stadt Köln, Lehrstuhl für Pneumologie der Universität Witten-Herdecke, Cologne, Germany.Pneumologische Praxis und pneumologischer Konsildienst im Klinikum Agnes Karll Laatzen, Klinikum Region Hannover, Laatzen, Germany.Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.Innere Medizin V: Pneumologie, Allergologie, Beatmungs- und Umweltmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.

Pub Type(s)

Journal Article
Practice Guideline

Language

eng

PubMed ID

32564028

Citation

Pfeifer, Michael, et al. "Position Paper for the State-of-the-Art Application of Respiratory Support in Patients With COVID-19." Respiration; International Review of Thoracic Diseases, vol. 99, no. 6, 2020, pp. 521-542.
Pfeifer M, Ewig S, Voshaar T, et al. Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19. Respiration. 2020;99(6):521-542.
Pfeifer, M., Ewig, S., Voshaar, T., Randerath, W. J., Bauer, T., Geiseler, J., Dellweg, D., Westhoff, M., Windisch, W., Schönhofer, B., Kluge, S., & Lepper, P. M. (2020). Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19. Respiration; International Review of Thoracic Diseases, 99(6), 521-542. https://doi.org/10.1159/000509104
Pfeifer M, et al. Position Paper for the State-of-the-Art Application of Respiratory Support in Patients With COVID-19. Respiration. 2020;99(6):521-542. PubMed PMID: 32564028.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19. AU - Pfeifer,Michael, AU - Ewig,Santiago, AU - Voshaar,Thomas, AU - Randerath,Winfried Johannes, AU - Bauer,Torsten, AU - Geiseler,Jens, AU - Dellweg,Dominic, AU - Westhoff,Michael, AU - Windisch,Wolfram, AU - Schönhofer,Bernd, AU - Kluge,Stefan, AU - Lepper,Philipp M, Y1 - 2020/06/19/ PY - 2020/05/29/received PY - 2020/05/29/accepted PY - 2020/6/22/pubmed PY - 2020/8/4/medline PY - 2020/6/22/entrez KW - Acute respiratory failure KW - COVID-19 KW - Respiratory support SP - 521 EP - 542 JF - Respiration; international review of thoracic diseases JO - Respiration VL - 99 IS - 6 N2 - Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order. SN - 1423-0356 UR - https://www.unboundmedicine.com/medline/citation/32564028/Position_Paper_for_the_State_of_the_Art_Application_of_Respiratory_Support_in_Patients_with_COVID_19_ DB - PRIME DP - Unbound Medicine ER -