This may be in part due to ARDS-like processes, including lung-protective ventilator strategies. Metabolic processes related to critical care, longer ventilator course, etc. There is no consensus on Active vs. After reviewing articles and consensus, we have concluded that facilities are pretty evenly split between the two, with maybe an edge given to those using active humidity.
There is a balance between what is best for patient secretions, mucociliary clearance and aersolization risk disconnects of circuit. HMEs and HMEFs may be a bit drier and allow for less aerosolization but requires regular circuit-breaks with changing of HME, while active humidity may allow for less disconnect but increases risk of aerosolization within a presumably closed circuit?
Equipment is also a consideration some hospitals just don't have enough active humidifier setups. Outside of COVID, we are not aware of any strong evidence for HME vs Active Humidity, most are split in terms of airway occlusion, mortality, incidence of secondary pneumonia see a meta-analysis by Vargas et al.
Extubation Procedure is covered in above section on Airway Management. See: Our Summarized Algorithm for Weaning. There is a strong consensus that proning a patient is a critical step in management, even pre-intubation Proning may improve ventilation-perfusion matching which can increase oxygenation.
Use Airborne PPE if possible. The concept of "recruitable lungs" suggests that some lungs are "recruitable," others are less-so also referred to as PEEP-responsiveness. Gathering evidence can be one step in determining this.
Epoprostenol and Other Inhaled Pulmonary Vasodilators. If needed, consider boluses vs. If persistently high plateau pressures, consider hours of continuous SCCM. Our official position is in line with the majority of respiratory and medical professionals: Multiple Patients should not be put on a single ventilator.
MAJOR considerations include the need for both sets of lungs to have very similar lung mechanics compliances, resistance, respiratory quotient, BMI, etc. If hypothetically able to match and maintain match nearly impossible , these variables would need to stay the same in both patients the entire time impossible. At best this would require a Respiratory Therapist be very close to bedside, constantly monitoring, all the time.
Please let us know if there are troubleshooting areas you are facing that aren't listed here yet. Secretions thick, tar-like Difficulty weaning despite evidence of resolving illness.
Check flow scalar does exp flow return to baseline? Suctioning and Bronchial Hygiene. Use of airway clearance to address excessive secretions, difficult to clear secretions, may be necessary but consider infection control due to increased risks associated with aerosolization WHO. Strong preference for closed suctioning only in-line suction when intubated WHO , CTS minimizes aerosolization exposure, decreases derecruitment of lungs alveoli collapse.
Consider use of self-directed bronchial hygiene, whenever possible Acapella, for example. Use MDI with spacer versus a nebulizer. One study showed active virus 3-hours in air sample after a nebulizer treatment assuming not in a negative pressure room Khoo et al ; Munster et. Choosing a Drug-Delivery Therapy in recommended order of preference, based on exposure risk, not drug deposition, etc. Protected Code Blue. Other specific recommendations: AHA.
There is no current evidence to support avoiding steroids, especially inhaled patients with Asthma, COPD, etc. Consider avoiding drugs that induce cough whenever possible mucokinetics such as acetylcysteine, hypertonic salines. Consider careful use with patients with abnormal secretions related to diseases - Cystic Fibrosis, Bronchiectasis, as needed when appropriate PPE is available, negative pressure rooms are preferred.
Several studies are looking at iNO as as option see critical care strategies section. Asthma Exacerbation: Consider use of Albuterol by MDI with spacer initially for exacerbation, every 20 mins x 3 doses. Consider IV mag if needed. Avoid continuous albuterol due to aerosolization risk unless absolutely necessary. Be aware of need for early intubation CHOP.
Systemic steroids should still be considered in severe asthma exacerbations benefits may outweigh risks WHO. Higher mortality. Aim for prevention when possible self-prone, mobility ASA. We are aware that there are many resources building out there. We are prioritizing what we see as the most useful resources. Please let us know if you think there's something that should be added.
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Basic Info. Caused by a virus thought to be Droplet Transmission but also uncertainty as to whether it is Airborne. In general, major symptoms often appear days after exposure, perhaps as few as 3 days omicron variant Current evidence is mixed on how much immunity a person has once recovered - the presence of antibodies Liu et al While there are predictable patterns there are individual variations in how COVID presents.
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