ARDS and ARF Won’t Disappear with the Pandemic

Respiratory failure/distress will outlive COVID-19 – but has the coronavirus created any improvements in ICU best practices for post-pandemic hospital care?

The world’s health and how healthcare was delivered underwent significant changes in late December, 2019 into spring and summer of 2020 as severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) emerged from China. The COVID-19 pandemic forced rapid moves in research to study the novel virus, develop quick, reliable diagnostic tests, develop effective vaccines, and work out strategies to care for all who were infected with the disease. Shutdown raced across the globe affecting almost every area of life and healthcare systems had to deal with overwhelming numbers of critically-ill patients and subsequent deaths due to the virus. This pandemic has brought change – and many aspects of healthcare have been altered as a result.

COVID-19 infection covers a spectrum of clinical phenotypes that exhibit symptoms ranging from mild, to moderate, to severe with subsequent hospital admission for some 15 to 20% of those with severe symptoms. 1,2 Of the hospitalized patients, about one quarter had to go into intensive care (representing some 5 to 8% of the total COVID-19 population).2 For those admitted to the ICU, most patients had acute respiratory failure (ARF) due to hypoxemia and high respiratory demand, and many moved quickly into acute respiratory disease syndrome (ARDS).2 Care in ICU was centered on improving oxygenation by utilizing various and increasingly complex devices including high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), non-invasive ventilation (NIV), and continuous mechanical ventilation (CMV). As healthcare professionals gained more experience and researchers uncovered more about the virus, strategies shifted and more targeted efforts were developed to reduce morbidity and mortality.

In the beginning weeks to months of fighting the disease, intubation and CMV received early priority if supplemental oxygen and usual care did not provide symptom-relief. However, this shifted to avoiding intubation, if possible, and using HFNC, CPAP, BiPAP or NIV combined with proning (either by the patient (self-proning) or by the staff).2 Possible release of infectious aerosols brought change in practice as expiratory filters were added to NIV and CMV circuits, tight fitting full-face masks were used for non-invasive interfaces and use of nebulizers to deliver medicated aerosols shifted to providing inhaled medication by metered-dose inhaler or dry powder inhaler if a suitable drug was available.1 As understanding of the disease expanded, different models were introduced to explain the rationale for changing approaches.3,4 Extensive infection control practices were put in place in both the healthcare setting and the community to emphasize handwashing, wearing masks, expanding personal space to 6 feet, and isolation to avoid exposure. Hospitals closed to visitors, opened COVID units, and emphasized use of personal protective equipment (PPE). Pulmonary function testing was delayed or dropped altogether. Invasive procedures were changed to reduce exposure and were delayed if possible (i.e. intubation, tracheostomy, bronchoscopy, surgery). New medications and vaccinations were developed and researchers studied many existing medications and combinations of medications to see if the course of the disease could be altered.

Management leaders did as much as possible to work out means for dealing with surges, lack of equipment, low staffing levels, scheduling, and morale.5 Systems evolved and changes were made in the electronic medical record to increase ways for sharing info with patients/providers. Improvements were made to remote monitoring, with more use of telemedicine, robots, tele-Grand rounds, and video conferencing. Care was expanded into the community using pharmacies, churches, community centers, and home visits along with care provided by drive-through/stay in the car approaches and more outpatient care. Improved support for long-term care, nursing homes were initiated through enhanced partnerships with acute care centers. Improvements were made to patient/family/provider communication and hospitals adjusted visitation strategies to enable virtual visits. At the same time much work was done in the study of inflammation, cytokine storm, and anti-viral medications.6 Disparities in healthcare came into the spotlight and changes were made to try and address this. Finally, many areas moved to early discussions on end of life issues.6 All of these came into play with the onset of the COVID-19 pandemic and although very few healthcare centers and systems were able to incorporate all of these changes, many were able to evolve and adapt to make significant change in the face of extremely difficult circumstances.

Many of the changes that occurred due to the pandemic are still in place and more refinement is occurring to improve efficiency and effectiveness, better infection control, improved communication, disease treatment and management, and more positive outcomes. Critical care practices have changed dramatically as better ways to care for these patients have been developed. Care for patients with ARF and ARDS due to other causes has been impacted as healthcare staff have seen what works with COVID-19 issues. With time, understanding is increasing for how to handle COVID-19 and lessons learned will help should another pandemic like this occur. Moreover, lessons learned in dealing with COVID-19 will help improve other aspects of care in not just ICU, but in most of the locales that provide care for patients.

References

Arunachalam PS, Wimmers F, Mok CK, Perera RA, Scott M, et al. Systems biological assessment of immunity to mild versus severe COVID-19 infection in humans. Science. 2020 Sep 4;369(6508):1210-20.
From the UpToDate website: https://www.uptodate.com/contents/covid-19-critical-care-and-airway-management-issues. Accessed 6/22/21.
Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. Jama. 2020 Jun 9;323(22):2329-30.
Vahidy FS, Pan AP, Ahnstedt H, Munshi Y, Choi HA, et al. Sex differences in susceptibility, severity, and outcomes of coronavirus disease 2019: Cross-sectional analysis from a diverse US metropolitan area. PloS one. 2021 Jan 13;16(1):e0245556.
Uptodate.com. 2021. UpToDate. [online] Available at: <https://www.uptodate.com/contents/covid-19-critical-care-and-airway-management-issues> [Accessed 22 June 2021]
Mudd PA, Crawford JC, Turner JS, Souquette A, Reynolds D, et al. Distinct inflammatory profiles distinguish COVID-19 from influenza with limited contributions from cytokine storm. Science advances. 2020 Dec 1;6(50):eabe3024.

About the author: Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a writer, lecturer, and consultant and recently retired from over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. He volunteers at the Pulmonary Clinic at Victory Health Partners in Mobile, AL, and is active in care for those with asthma, COPD, sleep disorders, and nicotine addiction.