Zhang Jingchen, He Xujian, Hu Jia, Li Tong
Department of Emergency, the First Affiliated Hospital, Zhejiang University, Hangzhou, China.
Medicine (Baltimore). 2020 Jul 2;99(27):e20843. doi: 10.1097/MD.0000000000020843.
Extubation strategy for mechanically ventilated patients with Coronavirus Disease 19 is different from that for patients with other viral pneumonia. We reported 2 cases of Coronavirus Disease 19 receiving tracheal intubation twice during the hospitalization.
Two elderly patients with onset of fever and upper respiratory tract infection were confirmed as Coronavirus Disease 19, 1 of whom had chronic obstructive pulmonary disease previously. With active antiviral and noninvasive respiratory supportive therapy, there was no improvement, thus mechanical ventilation (MV) was adopted. Combining with symptomatic and supportive treatment, their oxygenation recovered and then extubation was carried out. However, 96 hours later, they underwent endotracheal intubation again due to their Coronavirus Disease 19 progression.
Critically ill Coronavirus Disease 19 requiring tracheal intubation owing to respiratory failure with lung.javascript.
Initial Strategy for respiratory failure included endotracheal intubation, MV, antiviral treatment and cortisol in both cases. When extubation criteria were satisfied, early discontinuation of MV was conducted, then rehabilitation exercise and nutritional support followed. However, 96 hours later, the disease progressed leading to respiratory failure again, thus reintubation was performed. Later, veno-venous extracorporeal membrane oxygenation was performed owing to aggravation of respiratory failure, assisted by prone position treatment and sputum drainage, then status became stable and stepped into recovery stage.
Both patients underwent reintubation, and their MV time and Intensive care unit residence time were prolonged. Through prone position treatment, sputum drainage and awake extracorporeal membrane oxygenation strategy, patient has been transferred to rehabilitation unit in Case 1, and patient in Case 2 has been in recovery stage as well with stable pulmonary status and was expected to receive evaluation in recent future.
Course of Coronavirus Disease 19 is relatively longer, and failure rate of simple early extubation seemes higher. To reduce the likelihood of reintubation and iatrogenic injury, individualized assessment is recommended.
新型冠状病毒肺炎机械通气患者的拔管策略与其他病毒性肺炎患者不同。我们报告了2例新型冠状病毒肺炎患者在住院期间接受了两次气管插管。
两名老年患者因发热和上呼吸道感染起病，确诊为新型冠状病毒肺炎，其中1例既往有慢性阻塞性肺疾病。在积极进行抗病毒和无创呼吸支持治疗后病情无改善，遂采用机械通气。结合对症及支持治疗，患者氧合恢复后进行了拔管。然而，96小时后，由于新型冠状病毒肺炎病情进展，他们再次接受了气管插管。
重症新型冠状病毒肺炎，因呼吸衰竭伴肺损伤需要气管插管。
两例患者呼吸衰竭的初始策略均包括气管插管、机械通气、抗病毒治疗和使用皮质醇。当满足拔管标准时，早期停用机械通气，随后进行康复锻炼和营养支持。然而，96小时后，病情进展导致再次呼吸衰竭，因此再次插管。后来，由于呼吸衰竭加重，进行了静脉-静脉体外膜肺氧合，辅以俯卧位治疗和痰液引流，随后病情稳定并进入恢复期。
两名患者均再次插管，机械通气时间和重症监护病房住院时间延长。通过俯卧位治疗、痰液引流和清醒体外膜肺氧合策略，病例1的患者已转至康复科，病例2的患者也处于恢复期，肺部状况稳定，预计近期将接受评估。
新型冠状病毒肺炎病程相对较长，单纯早期拔管失败率似乎较高。为降低再次插管和医源性损伤的可能性，建议进行个体化评估。
