COVID-19 Critical Care + ventilation.pptx

Management
of the critically
ill patient with
confirmed or
suspected
COVID-19
Dr. Georg Kluge
Anesthesiologist-intensiivist
Bovenij Hospital Amsterdam

Virus: SARS-CoV-2
Disease: COVID-19

Sat 14th March
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Dutch ICU cases (n=2.925)
Mortality n=866 (29.6%)l

Figure 2
The Lancet 2020 395, 497-506DOI: (10.1016/S0140-6736(20)30183-5)
Copyright © 2020 Elsevier Ltd

Case definition CDC
> 2 of the following symptoms:
fever (measured or subjective), chills, rigors, myalgia,
headache, sore throat, new olfactory and taste disorder(s)
OR
> one of the following symptoms: cough, shortness of
breath, or difficulty breathing
OR
Severe respiratory illness with > one of the following:
Clinical or radiographic evidence of pneumonia, OR
Acute respiratory distress syndrome (ARDS).
AND
No alternative more likely diagnosis

Risk ICU admission or death (n=1099)
Age 63y vs 46y
Male 67.2% vs 57.5%
Former smoker 7.6% vs 1.6%
Current smoker 25.8% vs 12.8%
COPD 10.4% vs 0.5%
Diabetes 26.9% vs 6.1%
Hypertension 35.8% vs 13.7%
Guan WJ et al, NEJM 2020

Clinical Course
• Severe Acute Respiratory Infection (SARI)
• Type I respiratory failure (often hypocapnic)
• ARDS
• Near normal compliance lungs
• Severe shunt
• Secondary Complications
– Septic Shock
– Acute Renal Failure
– Myocarditis
– Thromboembolism (PE, AMI, iCVA)
• 7-10 days IPPV required

Laboratory testing for COVID-19
• 2 Viral swabs available in a pre-prepared pack
–1 deep nasopharyngeal swab and
–1 deep throat swab in viral transport medium
• lower respiratory specimen is strongly
recommended in severe or progressive disease.
• A positive alternate pathogen does not necessarily
rule out COVID-19 as little is yet known about the
role of co-infections.

Laboratory results
• Lymphocytosis
•  CRP
•  Ferritine
•  D-dimer
•  LDH

Transmission
• Direct contact (hand to mucus membrane)
• Droplet (contact within 1m of infected
patient)
• Aerosols: Smaller airborne particles which
can travel around a room

FFP2/3 or surgical mask (over NP)
Mask or Non-rebreather for Transfer

Personal Protective Equipment
• FFP2/3 Filter Mask
• Visor or Goggles (glasses not sufficient)
• Long sleeved water resistant gown
• Gloves
• Hat

Technique for Donning and Doffing of PPE
Donning
1. Perform Hand hygiene
2. Put on Gown and hat
3. Put on FFP3 mask
• Fit Check Mask
• Place mask over nose, mouth and chin
• Fit flexible nose piece over nose bridge
• Secure on head with elastic
• Adjust to fit
• Inhale- mask should collapse
• Exhale- check for leakage around face
• 4. Put on Eye Protection – goggles or face
shield
• 5. Put on gloves
Doffing
In the patients’ room
1. Remove Gloves
3. Remove Goggles –avoid touching the front
4. Remove Gown -avoid touching the front of the apron/gown
In ante room or directly outside patients' room-
Ensure door is closed
1. Remove Mask
Grasp and lift ties from behind your head and pull off respirator away from your face.
Avoid touching the front of the respirator and use ties to discard.
https://www.youtube.com/watch?v=Gy4StHAHMU4 https://www.youtube.com/watch?v=pNirkWLjMX0

Aerosol generating procedures
• Procedures that produce aerosols of respiratory
secretions carry an increased risk of transmission:
– NIV/CPAP/HFNC
– bronchoscopy
– induced sputum
– positive-pressure ventilation via a face mask
– intubation and extubation
– airway suctioning
– CPR

Critical Care Equipment
• Protect respiratory equipment with a high efficiency
filter (eg BS EN 13328-1).
• Use disposable respiratory equipment where possible
• Decontaminate re-usable equipment in accordance
with the manufacturer’s instructions
• Use closed suctioning systems
• Ventilator circuits should not be broken unless
necessary
• Place ventilators on standby when carrying out bagging
• Wear PPE at all times
• Consider a HME filter rather than water humidification

Operating theatre
• Decisions regarding the need for surgery during the period of
infectivity should be made by senior clinicians.
• Patient should be anaesthetised and recovered in the operating
room
• Staff should wear appropriate PPE
• Disposable anaesthetic equipment should be used where possible
• The anaesthetic machine should be protected by a filter with viral
efficiency of 99.99%
• Reusable anaesthetic equipment should be decontaminated as per
manufacturer’s instructions
• Operation room should be cleaned and disinfected after use
• Operating room should not be used for 15 minutes after patient
leaves (based on a conventional ventilation system with 20 air
changes per hour)

• Start march 2020, 8 June 2020 recruitment halted
• 2104 patients dexamethasone 6 mg once per day iv
or po for 10 days vs 4321 patients usual care alone
• 28-day mortality:
• 41% on ventilation OR 0.65 [0.48 to 0.88]; p=0.0003
• 25% oxygen only OR 0.80 [0.67 to 0.96]; p=0.0021
• 13% no oxygen OR 1.22 [0.86 to 1.75]; p=0.14)
• NNT 8 ventilated patients
• NNT 25 patients requiring oxygen alone
RECOVERY (Randomised Evaluation of
COVid-19 thERapY) trial (n=11.500)

Remdesivir Adaptive Covid-19
Treatment Trial (n=1063)
Median time to recovery 11 days vs 15 days
= 31% faster (p<0.001)
Survival benefit, mortality rate 8.0% vs
11.6% (p=0.059)
Contraindications: septic shock, organ failure

Respiratory Support
• NIV/HFNC/Mask CPAP not contraindicated but
results in aerosol production-must be delivered
in a negative pressure isolation room
• Most patients will have type I resp failure but
require higher levels of CPAP than can be
delivered with HFNC
• Helmet CPAP may be the best NI option where
available
• Full face mask NIV may be an option
• The rate of failure of NIV with COVID-19 is high
• In general early IPPV is encouraged

High flow nose canula (HFNC)
Flow 60L/min
FiO2 60%
PEEP 6mmHg

Continuous positive airway
pressure (CPAP)
note: IPAP (+15 cmH2O) is the PSV value and
EPAP (+5 cmH2O) is the CPAP value = NIV

Continuous positive airway
pressure (CPAP)
Biphasic intermittent positive airway pressure (BIPAP)
note: CPAP (+5 cmH2O) is maintained
during spontaneous breathing
note: IPAP (+15 cmH2O) is the PSV value and
EPAP (+5 cmH2O) is the CPAP value = NIV

Non invasive ventilation (NIV)
• CPAP / BIPAP mode possible
• Alveolar recruitment 
• Work of breathing 
• expiratory flow 
• Type 1 resp. failure (hypoxia only)

Non invasive ventilation (NIV)

Mechanical ventilation
• Defined by:
1. FiO2 (21%)
2. Inspiration : expiration (I:E) ratio (1:2)
3. Frequency (15x/min)
4.a Volume or (8ml/kg)
4.b Pressure pmax (-3 to +3 cmH2O)
5. PEEP (0 cmH2O)

Continuous positive pressure
ventilation (CPPV)
Assist/Control (A/C)
Volume controled ventilation
• I:E 1:2
• FiO2 100%
• Frequency 20/min
• Volume 420 ml
• Peep 8 cm H2O
• which parameter is important to monitor?

Dynamic en static Compliance
defined by dynamic airway
resistance - obstructive
defined by static compliance
of lung and thorax -
restrictive
Compliance = (V/p)

Follow up
• BGA: pH 7,24, paCO2 51 mmHg, paO2 56 mmHg, Bic.
18 mmol/l, BE –5,3 mmol/l, SaO2 85%
• I:E 1:2, FiO2 100%, f= 20/min , VT 420 ml, Peep 8 cm
H2O
• Ppeak 48 cmH2O
• Pplat 33 cm H2O
• no PEEPi

Interpretation Astrup
• hypoxia
• hypercapnia
= Type II resp. insufficiency
(only hypoxie = Type I resp. insufficiency)
• ? P/F ratio?
• paO2 / FiO2 = 56 / 1,0 = 56
• normal: 101 / 0,21 = 500
• (ARDS < 200, ALI < 300)
• bij FiO2 1,0: 721 / 1,0 = 721

Possible adaptations ventilation
• BGA: pH 7,24, paCO2 51 mmHg, paO2 56 mmHg, Bic. 18
mmol/l BE –5,3 mmol/l, SaO2 85%
• FiO2 100%, CPPV 20 x 420, PEEP 8, 1:2
• ventilation frequency
• Pressure controlled ventilation
• Increase PEEP
• Inversed ratio ventilation (I:E)

Follow up 2
• Ventilation frequency increased to 24 / min
• I:E, VT unchanged
• pplat = 38 cmH2O
• BGA: pH 7,34 paCO2 44 mmHg,
paO2 53 mmHg, Bic. 20 mmol/l
BE –3,3 mmol/l, SaO2 84%

Why improves pCO2 and not pO2?
• Improvement alveolar ventilation
• No recruitment of alveoli
• f, VT -> impact ventilation -> pCO2 
• PEEP, I:E-ratio -> impact oxygenation -> pO2 

Which ventilation modes can
improve oxygenation?
• PCV
• BIPAP
•  PEEP
• IRV (Inversed ration ventilation 1:1 -> 2:1)
• APRV (Airway pressure release ventilation)

Follow up 3
• PCV 45/15, I:E 1:1, f = 15 / min
• How long are in- and expiration time?
• 2:2 sec
• Which variable becomes important now?

Intrinsic PEEP
• Created by dynamic hyperinflation of the lung
with airtrapping resulting in extra PEEP
• PEEPi to create and to manipulate:
1. adapt I:E ratio = Inversed ratio ventilation (IRV)
2. increase ventilation frequency

Which circulatory problems are
to expect?
•  venous return  BP   fluids!
•  pulmonry resistance
  afterload right ventrikcl
•  Ptransmural left ventricle 
 left ventricle tension T = PtM x R/2H
 O2 – use of ventrikle 
 contractility 

Advantages PCV vs CPPV
• decelererating flow
=> more laminary flow endinspiratory
=> more even distribution of
ventilation at patiënts with
different resistances in lung
compartments
• 1 study (Esteban et al, Chest 2000)

In-hosp. Mortality 33 (78) 19
(51) 0.02
Barotrauma 4 (9) 6
(16) 0.18
ICU LOS, d 25 ± 19 21 ±
15 0.46
Hospital LOS, d 30 ± 24 27 ±
20 0.84
Extrapulmonary 3.7 ± 1.8 2.6 ± 1.5 0.005
organ failures , No.
Cardiovasc. Failure 33 (78) 25
(67) 0.39
Renal failure 27 (64) 12
(32) 0.009
Liver failure 18 (43) 9
(24) 0.13
Coagulation failure 22 (52) 12
(32) 0.12

PCV vs CPPV 2
• but: multivariate analysis:
• Predictors of mortality were only
multiorgan failure (> 2 organs) and acute
kidney failure, not volume controleed
ventilation.

Ventilator induced lung injury (VILI)
• Standard protective ventilation
– Tidal Volume 6 ml/kg IBW
– Plateau pressure < 30 cm H2O
– Driving Pressure < 15 cm H2O
– Early NDMR if indicated
– Appropriate PEEP / IRV
– Prone Ventilation if indicated
– Daily CXR may not be neccessary

Ventilation with high/ low VT
• 861 patients with ARDS
• groop 1: ventilation with VT = 6 ml/kg
• groep 2: ventilation with VT = 12 ml/kg
• mortality: 31% vs. 39,8% (p= 0,007)
• ventilator free days at day 28: 12 vs. 10
(p=0,007)
The ARDS network, NEJM 2000, 342: 1301-8

Ventilation with ppeak 45cmH2O
Mice lungs after 0, 5 en 20 min ventilation with 45 cmH2O

Name 3 causes of acute
decrease of VT?
• Airway obstruction due to
• asthma, exac. COPD, coma, kinked tube,
sputum plug
• Restrictive causes:
• pneumothorax,
• unilateral intubation
• barotrauma
• Lung oedema

COVID-19 pneumonia, Type L
At the beginning, patients not short of breath:
• Low elastance: the nearly normal compliance indicates that
the amount of gas in the lung is nearly normal
• Low ventilation to perfusion (V/Q) ratio: since the gas
volume is nearly normal, hypoxemia may be best explained
by the loss of regulation of perfusion and by loss of hypoxic
vasoconstriction.
• Low lung weight: Only ground-glass densities are present
on CT scan, primarily located subpleurally and along the
lung fissures. Consequently, lung weight is only moderately
increased.
• Low lung recruitability: the amount of non-aerated tissue is
very low, consequently the recruitability is low
G
a

COVID-19 pneumonia, Type L
• Modest local subpleural interstitial vasoplegia ->
severe hypoxemia.
• Normal response to hypoxemia: increase minute
ventilation, primarily by increasing the tidal volume
(up to 15-20 ml/kg)
-> more negative intrathoracic inspiratory pressure.
• The near normal compliance, however, explains why
some of the patients present without dyspnea as the
patient inhales the volume he expects.
• This increase in minute ventilation leads to a
decrease in PaCO2.
Gattinoni L. et al. Intensive Care Medicine 2020

Treatment Type L resp. failure
1. Increase FiO2
2. non-invasive respiratory support
- High Flow Nasal Cannula (HFNC)
- Continuous Positive Airway Pressure (CPAP)
- Non Invasive Ventilation (NIV).

Monitoring Type L resp. failure
• Measurement (or estimation) of inspiratory esophageal
pressure swings.
• In the absence of the esophageal manometry, surrogate
measures of work of breathing: swings of central venous
pressure, or clinical detection of excessive inspiratory effort
• The magnitude of inspiratory pleural pressure swings may
determine the transition from the Type L to the Type H
phenotype.
• As esophageal pressure swings increase from 5-10 cmH2O
(generally well tolerated ) to > 15 cmH2O, the risk of lung
injury increases and therefore intubation should be
performed as soon as possible.
• In intubated patients: P0.1 and P occlusion

Swings of central venous pressure

NIV in Type L resp. failure
High PEEP may decrease the pleural pressure
swings and stop the vicious cycle that exacerbates
lung injury.
However, high PEEP -> high intrathoracic pressure -
> theses pts. with normal compliance ->  BP
High failure rates and delayed intubation, in a
disease which typically lasts several weeks.

Ventilation in Type L resp. failure
• If hypercapnic, can be ventilated with volumes
greater than 6 ml/kg (up to 8-9 ml/kg) as the high
compliance results in tolerable strain without the
risk of VILI.
• Prone positioning should be used only as a rescue
maneuver, as the lung conditions are “too good”
• PEEP should be reduced to 8-10 cmH2O, given that
the recruitability is low and the risk of hemodynamic
failure increases at higher levels.
• Early intubation may avert the transition to Type H
phenotype.

COVID-19 pneumonia, Type L -> H
• Severity of the disease itself + depth of the negative
intrathoracic pressure
-> negative inspiratory intrathoracic pressure
+ increased lung permeability due to inflammation
-> interstitial lung edema = self Inflicted Lung Injury (P-SILI)
j
->  lung weight
->  superimposed pressure
->  dependent atelectasis
-> decreased gas volume -> decreased tidal volumes
=> dyspnea -> vicious circle worsening P-SILI

COVID-19 pneumonia, Type H
• High elastance:  edema ->  gas volume ->  compliance
•  right-to-left shunt: fraction of cardiac output perfuses the
non-aerated tissue developing in the dependent lung regions
• High lung weight: Quantitative analysis of the CT scan shows
a remarkable increase in lung weight (> 1.5 kg), on the order
of magnitude of severe ARDS
• High lung recruitability: The increased amount of non-
aerated tissue is associated, as in severe ARDS, with
increased recruitability.
• The Type H pattern, 20 – 30% of patients in our series, fully
fits the severe ARDS criteria: hypoxemia, bilateral infiltrates,
decreased respiratory system compliance, increased lung
weight and potential for recruitment.

Ventilation in Type H resp. failure
• Should be treated as severe ARDS:
• High PEEP, if compatible with hemodynamics, up
to 20cmH2O
• Inversed ratio ventilation: I:E 1:2 -> 1:1 -> 2:1
• Prone positioning: normalizes V/Q mismatch

PEEP + Inversed ratio ventilation
Recruitment of collapsed alveoli +
prevention of alveolar collaps by:
a.  FRC   shunt
b.  shear stress of alveoli

CT-scan ARDS
Lawrence R et al. Radiology 1999;213:545-552

Lung changes in ARDS (CT-scan)
Ventral
Dorsal
decreasing
consolidations

Effects prone position
•  transpulmonary pressure
• -> recruitment alveoli ->
•  shunt ( ventilation / perfusion)
•  lung compression mediastinal structures
•  cardiac output
•  hypoxic pulmonary vasoconstriction

Prone position 17u
Prone Positioning in Severe ARDS. N Engl J Med 2013; 368:2159-2168

Prone position 17h
Prone Positioning in Severe ARDS. N Engl J Med 2013; 368:2159-2168

Practical prone positioning
• protect pressure points (eyes, nose, genitals)
• take off ECG leads
• preoxygenate FiO2 100%
• watch tube – handpalm on patient face
• watch art. + central lines
• auscultate
• apply monitoring
• recruitment (3 x ventilation with pmax 50cmH2O)

How to do it?
https://www.youtube.com/watch?v=JSenKtvfNZ8

Recruitment
• „open the lung and keep the lung open“
(Lachmann, Rotterdam)
• high pressures necessary because in ARDS:
1.) viscosity of fluid along collapsed lung
2.) high surface tension in this region

Recruitment 2
• Healthy lung areals are being overdistended for a
short while -> SpO2 ↓ 1-2% for some seconds
• paO2 , especially in prone position
• If lung collapses: repeat maneuvre and increase
PEEP to keep open recruited lung areals 
• omit shear-stress
•   inflammation,  FiO2 necessary,  inactive
surfactant
• beware: barotrauma, dramatic BP  in
hypovolemic patients, alveolar-capillary injury
Nieszkowska A et al, Crit Care Med 2004;32:1496-503

ARDS & recruitment maneuvre
3 breaths with Pplat. 45 mm Hg
Pelosi P, et al. Am J Respir Crit Care Med 1999;159:872 - 880

Weaning from ventilation
Prerequisites:
• FiO2 < 0,4
• PEEP < 14
• f < 30/min
• I:E = 1:2
• VT 6 ml/kg
• ABG: normocapnic / normoxic
• CXR: no pulmonary oedema
• No gross peripheral oedemas
• Hemodynamically stable, low dose noradrenaline ok

Weaning from ventilation
• Stop analgosedation (beware  kidney function)
• Switch to CPAP/ASB (augmented spontaneous
breathing) –
• PSV (pressure support ventilation) 14 + 20 cmH2O
• PEEP according to oxygenation -> 12 -> 10 -> 8 ->
5cmH2O
 PS according to f -> +12 -> + 10cmH2O, aim f <25/min
• If PSV 5 + 10cmH2O: 30 min. Swedish nose
• If f <25/min -> extubation

Preventing Infection while on CPPV
• Closed circuit suctioning
• High efficiency filter (eg BS EN 23328-1)
• Minimise circuit breaks
• Clamp ETT if circuit breaks necessary

Analgosedation
Analgesia:
• Fentanyl 50-100ug/h or
• Morphine 1.5 – 2.5mg/h iv
Sedation
• Propofol 3-5mg/kg/h iv
• Midazolam 2-5mg/h iv
• Clonidine 75-150ug/h iv
• Give boli before procedures (turning / proning)

Treatment of shock /thrombosis
• As per surviving sepsis guidelines
• Early use of noradrenaline via iv pump, aim
MAP > 65mmHg
• Avoid excessive volume administration
• Give double dose thromboprophylaxis
• Watch for PE / myocardial ischemia / iCVA /
thrombi v. jug. int. & v. fem.
• In RRT: regional citrate AND systemic heparine
anticoagulation

Acute kidney injury (AKI)
• AKI developed in 36.6% of admitted patients
• Most commonly early in disease
• Of all patients who developed AKI, 14.3%
required renal replacement therapy [RRT]
• AKI most frequently developed in patients
with respiratory failure
• 89.7% of patients on mechanical ventilation
developing AKI compared to 21.7% of non-
ventilated patients.
Kidney International 2020

Figure 2
The Lancet DOI: (10.1016/S0140-6736(20)30566-3)

Inter Hospital transfer
and COVID-19
• May be occasionally
required
• Standard inter-hospital
protocols apply with
additional infections
prevention and control
precautions (full PPE
worn by all crew and
appropriate ventilator
tubing filters)

Conclusions
• COVID-19 is a novel coronavirus that causes
severe hypoxic respiratory failure in about 5%
of cases
• Mortality is high in patients who require ICU
admission
• The scale of infection will put ICU capacity
under severe pressure
• There is no directed treatment or vaccine

Main priorities for critical care teams
• Be prepared
• Triage appropriately
• Prevent HCW and nosocomial infection
• Intubate early?
• Conservative fluid strategy for shock
• Supportive care is the mainstay of treatment
• Typically require long periods of IPPV (7-10
days)

Suggested ARDS Mechanical
Ventilation Protocol
For Confirmed or Suspected COVID-
19
March 2020

ACUTE HYPOXIC RESPIRATORY FAILURE – PF RATIO <200
COVID 19 PRESENT OR SUSPECTED
Conservative Fluid Strategy or Furosemide
ANTIBIOTICS
OXYGEN THERAPY via FACEMASK – Target PO2: 8 – 10kPa, SaO2>90
IMPROVED PFR >200
Reassess at 30 mins. IF P:F ratio <200 consider intubation
IF NOT IMPROVED AT 12 HOURS (P:F ratio < 150, respiratory distress) INTUBATE
INTUBATE AND VAC-PEEP – Propofol/Remi Sedation
NOT IMPROVED PFR<200
Consider CPAP via HELMET (if available)– 5-10cmH2O COVID 19 negative?
HFNC ok
Patient Suitable for Critical Care?

Acute Hypoxic Respiratory Failure due to COVID19 PaO2/FiO2<200
Intubate – VAC Ventilation
TV 350ml Female (adjust)
TV 425ml Male (adjust)
Sedate to RASS -4
Limited use of RM*
PEEP = 10cmH2O
PaO2/FiO2 >125
Bilateral Infiltrates CXR
Moderate ARDS
PaO2/FiO2 <125
Bilateral Infiltrates CXR
Moderate-Severe ARDS
Continue sedation RASS-4
Administer Cis-Atracurium
Sedate to RASS -2
Continue Vent Strategy
After 2 hours reassess

Moderate to Severe ARDS PaO2/FiO2<125
AC Ventilation
Sedate to RASS -4
Cisatracurium (BIS <60)
TV<6ml/kg IBW
PEEP/Paw Adjusted to
Keep PaO2 >8kPa
Consider APRV
PaO2/FiO2 >200
PaO2/FiO2 >100 <200
Moderate ARDS
PaO2/FiO2 <100
Turn off NDMR
Vent Liberation Protocol
Every 4 hours reassess
Discontinue NDMR after
48 hours, Reassess PFR
Continue cisatracurium
For 48 hours
Consider iNO/ECMO*
Turn the patient
PRONE for 16 hours
Reassess every 2 h
No Improvement

At 24h PF Ratio > 200
COVID-19 Negative
PEEP <10 and Lung Compliance >40ml/cmH20
Wean Sedation
Wean to PSV
Liberate to HFNC / CPAP
Liberate to Oxygen by Facemask
Max flow 6L
COVID-19 Positive
No
Yes
Liberate Only When PFR >250
Continue Mechanical Ventilation
Ventilator Liberation Protocol

ARDSnet PEEP Protocol
(for type H resp. failure)

FEMALE
HEIGHTfeet HEIGHT cm TV 6ml/kg
5' 0 152.4 275
5' 1 155 290
5' 2 158 300
5' 3 160 315
5' 4 163 330
5' 5 165 340
5' 6 168 360
5' 7 170 370
5' 8 173 385
5' 9 175 400
5' 10 178 410
5' 11 181 425
6' 0 183 440
6' 1 186 450
6' 2 188 465
6' 3 191 480
6' 4 193 495
350ml
MAXIMAL ALLOWABLE TIDAL VOLUMES BASED ON PREDICTED BODY WEIGHT
(PBW)

MALE
HEIGHT feet HEIGHT cm TV 6ml/kg
5' 0 152.4 300
5' 1 155 315
5' 2 158 330
5' 3 160 340
5' 4 163 355
5' 5 165 370
5' 6 168 385
5' 7 170 400
5' 8 173 410
5' 9 175 425
5' 10 178 440
5' 11 181 450
6' 0 183 465
6' 1 186 480
6' 2 188 495
6' 3 191 505
6' 4 193 520
425ml
MAXIMAL ALLOWABLE TIDAL VOLUMES BASED ON PREDICTED BODY WEIGHT
(PBW)

Casus report Covid-19
Bovenij shopital Amsterdam

Cijfers
• Covid-19 positieve admissions: 19
• On invasive ventilation: 15
• CVVH: 6 patiënts = 32%
• Risk factors:
– age 36-84 jaar, median 70 jaar
– DM: 10 = 53%
– Hypertension: 14 = 74%
– Obesity: BMI 27

Deceased IC patients BovenIJ
• 9 patiënts = 47%
• Knowledge now: 3 or 4 retrospectively shouldn’t have
been admitted due to frailty, treatment objection, age in
combination with comorbidity
• Risc factors:
– age 65-84 jaar, gemiddeld 75
– DM 5 = 56%
– Hypertension 7 = 78%
– Obesity: BMI 27

Case mr. O
• Male, 56 y
• PMH/
– IDDM
– Hypertension
– Smoking ++ (not active)
– Fatty liver
• Home medication: statins, insuline, irbesartan,
pantoprazol

X-thorax at presentation 1 april

Synopsis 1
1 april: presentation A&E -> Acute admission unit
2 april: CT-thorax due to hemoptoë, no result
Covid-test. CT: giant bullae, interstitial lung
changes, Co-Rads 4

Synopsis 2
5 april: from Acute admission unit -> IC due to
increasing O2 need, non-rebreathing mask 15L/min
7 april: intubation, prone position
13 april: no improvement, hoge ventilation
pressures, prone position
14 april: BAL, suspection aspergillus -> start
voriconazol/amphotericine B
15 april: AKI, start CVVH

Synopsis 3
19 april: start steroids (aspergillus not suspected
anymore)
22 april: improvement, supine position
29 april: placement trachea canula
7 mei: weaning goes well, still on CVVH
26 mei: nieuw resp. Failure, intubation adn
prone position, start broad spectrum antibiotics

Synopsis 4
• 2 juni: improvement, weaning
• 10 juni: pneumothorax, thoraxdrainage
• 15 juni: persisting air leakage
• 18 juni: thoraxdrain out
• 20 juni: trachea canula out, CVVH stop
• 29 juni: to ward!
• 3 juli: to revalidation unit
(86 dagen intensive care, 92 days hospitalized)

Useful Resources:
https://www.intensivecare.ie/wp-content/uploads/2020/02/ICS-Guidelines-COVID-19-V2-1.pdf
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-
infection-when-novel-coronavirus-(ncov)-infection-is-suspected
https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/algorithms/
https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/
https://www.nejm.org/coronavirus?cid=DM88295&bid=163494080

COVID-19 Critical Care + ventilation.pptx

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