Care for Critically Ill Patients With COVID-19

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Appreciating typical clinical features and disease course are crucial both to prepare for increasing numbers of patients and to determine how to best treat infected persons. Patients who have required critical care have tended to be older (median age ≈60 years), and 40% have had comorbid conditions, commonly diabetes and cardiac disease.² Children generally have been observed to experience a milder illness, although perinatal exposure may be associated with substantial risk. The small numbers of pregnant women infected thus far have had a mild course,³ but limited cases make predictions about disease course uncertain; however, severe illness in pregnant women was a major concern with influenza A(H1N1)pdm2009. The median duration between onset of symptoms and ICU admission has been 9 to 10 days, suggesting a gradual deterioration in the majority of cases.⁴ The most documented reason for requiring intensive care has been respiratory support, of which two-thirds of patients have met criteria for acute respiratory distress syndrome (ARDS).²

Given the presence of a number of circulating respiratory viruses, differentiating COVID-19 from other pathogens, particularly influenza, is important and chiefly done using upper (nasopharyngeal) or lower (induced sputum, endotracheal aspirates, bronchoalveolar lavage) respiratory tract samples for reverse transcriptase–polymerase chain reaction and bacterial cultures. There are suggestive but nonspecific radiographic changes, such as ground-glass opacities on computed tomography.² Rapid access to diagnostic testing results is a public health and clinical priority, allowing for efficient patient triage and implementation of infection control practices.

Management of severe COVID-19 is not different from management of most viral pneumonia-causing respiratory failure (Figure). The principal feature of patients with severe disease is the development of ARDS: a syndrome characterized by acute onset of hypoxemic respiratory failure with bilateral infiltrates. Evidence-based treatment guidelines for ARDS should be followed, including conservative fluid strategies for patients without shock following initial resuscitation, empirical early antibiotics for suspected bacterial co-infection until a specific diagnosis is made, lung-protective ventilation, prone positioning, and consideration of extracorporeal membrane oxygenation for refractory hypoxemia.⁵