1Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
2Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Am J Trop Med Hyg. 2021 Jan 13;104(3_Suppl):60-71. doi: 10.4269/ajtmh.20-0796.
Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.
来自中低收入国家的经验
严重或危重新冠肺炎患者的管理主要是仿照其他病因导致的严重肺炎或急性呼吸窘迫综合征（ARDS）患者的治疗方法，而这些建议是基于源自资源丰富的高收入国家重症监护病房调查的证据。通常，将这些建议应用于资源有限的环境中并不实际，尤其是在中低收入国家（LMICs）。我们报告了一套适用于资源有限环境下（尤其在中低收入国家）严重/危重新冠肺炎患者急性呼吸衰竭和机械通气管理的实用建议。我们建议当 SpO2 持续低于 94%时开始补充氧气。我们建议补充氧气以将 SpO2 维持在 88-95%，并建议在无法持续进行脉搏血氧饱和度监测但可以间歇性进行脉搏血氧饱和度监测的情况下设定更高的目标。我们建议对持续低氧血症的患者尝试清醒俯卧位通气；然而，这需要密切监测，并明确失败和升级标准。在有足够数量和训练有素的工作人员的地方，这种策略似乎是安全的。我们建议根据呼吸窘迫的迹象而不是单纯的难治性低氧血症来进行插管，并且建议密切监测呼吸恶化情况，如果出现恶化则尽早进行插管。我们建议根据高 FiO2/低 PEEP 表进行低潮气量通气，并结合 FiO2 和呼气末正压（PEEP）管理。我们建议避免常规使用肺复张手法，除非是难治性低氧血症的抢救性治疗，并且建议在插管患者中对难治性低氧血症（PaO2/FiO2 < 150 mmHg、FiO2 ≥ 0.6 和 PEEP ≥ 10 cmH2O）使用俯卧位通气 12-16 小时，这是 ARDS 患者的标准治疗方法。我们还建议避免为多位患者共用一台呼吸机。我们建议每天通过低水平压力支持进行脱机准备评估，并建议避免使用 T 型管试验，因为存在气溶胶化风险。
