The document discusses treatment recommendations for patients experiencing severe acute respiratory distress syndrome (ARDS) from COVID-19. It provides guidance on use of extracorporeal membrane oxygenation (ECMO) and other evidence-based options for managing hypoxemia and respiratory failure in COVID-19 patients, including high-flow nasal oxygen, mechanical ventilation strategies, prone positioning, neuromuscular blockade, inhaled nitric oxide, fluid management, and antibiotics. It acknowledges challenges in scaling up ECMO globally and emphasizes optimizing other established treatment protocols.
Although there are no large epidemiological studies from India, mortality data on total number of deaths from lower respiratory tract infection are available. Whereas the world wide mortality of CAP in hospitalised patients varies from 14%–50%, the reported mortality in India varies from 3.3% to 40% with higher rates in elderly & in those requiring intensive care unit (ICU) care. Use of clinical scores like CURB-65, & CRB 65 help to stratify risk of severe disease & need for hospitalisation & ICU care. Early initiation of appropriate antibiotic based upon the knowledge of local resistant patterns of existing pathogens is the key for successful treatment.
Community Acquired Pneumonia IntroCommunity-acquired pneumo.docxcargillfilberto
Community Acquired Pneumonia: Intro
Community-acquired pneumonia (CAP) is a common group of infectious diseases that are responsible for significant global health and economic burden. CAP affects approximately 5.5/1000 people annually, and is a leading cause of hospital admissions, morbidity, and mortality in developed countries (especially for older people). Among all patients with CAP, those aged 65 or older account for about one-third, but they account for more than half of all health costs due to this disease. COPD is one of the most common comorbidities in patients with CAP, characterized by persistent respiratory symptoms. COPD was the third-most common cause of death in 2008, and the morbidity from COPD is projected to increase by 2020 (Liu, Han, & Liu, 2018).
Brief Summary of Client Case
Client HH is a 68 year-old male admitted with a diagnosis of community-acquired pneumonia for the past 3 days. This client’s medical HX includes COPD, HTN, hyperlipidemia, and diabetes. Mr. HH is on day three of two empiric antibiotics (ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily). The client’s clinical status has improved since admission, with decreased oxygen requirements. However, he is not tolerating anything PO at this time and complains of nausea and vomiting. The client’s height is 5’8” and he weighs 89 kg. The only known drug allergy is PCN which results in a rash.
Analysis
The client in this scenario is responding well to the current antibiotic therapy, as evidence by a drop in WBC count from 18.2 upon admission to 14.6 currently (normal range is between 5.0 and 10). It is also pleasing that the client’s O2 saturation is now 92% on room air alone, compared to 90% while requiring 4L of supplemental oxygen upon admission. Overall, the client’s lab results are not significantly concerning. Neutrophil (normal range 40-60%) and band (normal range 0.0-03%) percentages are slightly elevated as expected given the infectious process (NIH, 2020). Aside from an elevated WBC count that is trending down, a marginally elevated blood glucose, and a HCO3 elevated eight points above the normal limit, the other lab results are within the normal ranges of a healthy adult male (Farinde, 2019). The issues of concern in this client case are the client’s inability to tolerate a diet due to nausea and vomiting, elevated temperature, and continuing antibiotics to treat the pneumonia.
Treatment Considerations
According to Donovan (2019), the client’s empiric antibiotic regime is consistent with what is recommended by the Infectious Diseases Society of America (IDSA). Initial empiric antimicrobial treatment should be initiated until laboratory results can be obtained to guide more specific therapy. Also, a combination of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8h or ceftaroline 600 mg IV q12h) plus azithromycin 500 mg IV q24h is consistent with IDSA guidelines for a client with comorbidities such as COPD and diab.
Community Acquired Pneumonia IntroCommunity-acquired pneumo.docxdrandy1
Community Acquired Pneumonia: Intro
Community-acquired pneumonia (CAP) is a common group of infectious diseases that are responsible for significant global health and economic burden. CAP affects approximately 5.5/1000 people annually, and is a leading cause of hospital admissions, morbidity, and mortality in developed countries (especially for older people). Among all patients with CAP, those aged 65 or older account for about one-third, but they account for more than half of all health costs due to this disease. COPD is one of the most common comorbidities in patients with CAP, characterized by persistent respiratory symptoms. COPD was the third-most common cause of death in 2008, and the morbidity from COPD is projected to increase by 2020 (Liu, Han, & Liu, 2018).
Brief Summary of Client Case
Client HH is a 68 year-old male admitted with a diagnosis of community-acquired pneumonia for the past 3 days. This client’s medical HX includes COPD, HTN, hyperlipidemia, and diabetes. Mr. HH is on day three of two empiric antibiotics (ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily). The client’s clinical status has improved since admission, with decreased oxygen requirements. However, he is not tolerating anything PO at this time and complains of nausea and vomiting. The client’s height is 5’8” and he weighs 89 kg. The only known drug allergy is PCN which results in a rash.
Analysis
The client in this scenario is responding well to the current antibiotic therapy, as evidence by a drop in WBC count from 18.2 upon admission to 14.6 currently (normal range is between 5.0 and 10). It is also pleasing that the client’s O2 saturation is now 92% on room air alone, compared to 90% while requiring 4L of supplemental oxygen upon admission. Overall, the client’s lab results are not significantly concerning. Neutrophil (normal range 40-60%) and band (normal range 0.0-03%) percentages are slightly elevated as expected given the infectious process (NIH, 2020). Aside from an elevated WBC count that is trending down, a marginally elevated blood glucose, and a HCO3 elevated eight points above the normal limit, the other lab results are within the normal ranges of a healthy adult male (Farinde, 2019). The issues of concern in this client case are the client’s inability to tolerate a diet due to nausea and vomiting, elevated temperature, and continuing antibiotics to treat the pneumonia.
Treatment Considerations
According to Donovan (2019), the client’s empiric antibiotic regime is consistent with what is recommended by the Infectious Diseases Society of America (IDSA). Initial empiric antimicrobial treatment should be initiated until laboratory results can be obtained to guide more specific therapy. Also, a combination of a beta-lactam (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8h or ceftaroline 600 mg IV q12h) plus azithromycin 500 mg IV q24h is consistent with IDSA guidelines for a client with comorbidities such as COPD and diab.
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
Assessment of the Implementation of Ventilator-associated Pneumonia Preventiv...IOSR Journals
Background: Pneumonia associated with mechanical ventilation (VAP) is one of the important
causes of nosocomial infections in pediatric intensive care units (PICU). VAP is the leading cause of morbidity
and mortality in PICUs. Aim: To assess the compliance to ventilator bundle components: elevation of the head
of bed >30, sedation interruption, spontaneous breathing trial, peptic ulcer prophylaxis and its effect on the
prevention of VAP. Subjects and Methods: A case control study at PICU of Abo EL Reish El Moneira Hospital,
including all mechanically ventilated patients admitted over a period of one year. The study tested the effect of
implementation of this bundle as regard the rate of VAP in both group, compliance to bundle and most affecting
component of it. Results: There was decrease incidence of VAP after implementation of the bundle, from (50%)
to (14%). Development of VAP was mostly affected by being in supine position, long duration of mechanical
ventilation and presence of pump failure. (p<0.05) The compliance to bundle components was statistically
significant, p= 0.001. Conclusion: VAP rate decreased after implementation of this bundle. Elevation of the
head of bed was the most compliant component of bundle in the PICU.
Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
COVID-19 Pneumonia in a Congenital Adrenal Hyperplasia; A Case Reportsemualkaira
Congenital Adrenal Hyperplasia (CAH) is managed with longterm corticosteroid and is suggested to higher dose, based on the
general sick day principles. I presented a 5-year-old CAH case
by pneumonia managed in our pediatrics department. Considering stress doses of cortisone in management of CAH patients with
COVID19 should be considered
Similar to Treatment for severe acute respiratory distress syndrome from covid 19 (20)
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Treatment for severe acute respiratory distress syndrome from covid 19
1. Comment
www.thelancet.com/respiratory Published online March 20, 2020 https://doi.org/10.1016/S2213-2600(20)30127-2 1
Treatment for severe acute respiratory distress syndrome
from COVID-19
InTheLancetRespiratoryMedicine,KollengodeRamanathan
and colleagues1
provide excellent recommendations for
the useof extracorporeal membraneoxygenation (ECMO)
for patients with respiratory failure from acute respiratory
distress syndrome (ARDS) secondary to coronavirus
disease 2019 (COVID-19).The authors describe pragmatic
approaches to the challenges of delivering ECMO to
patients with COVID-19, including training health-care
personnel, resolving equipment and facilities issues,
implementing systems for infection control and personal
protection, providing overall support for health-care staff,
and mitigating ethical issues. They also address some
of the anticipated challenges with local and regional
surges in COVID-19 ARDS cases; although there has been
an increase in hospitals with the capacity to provide
ECMO, the potential demand might exceed the available
resources. Furthermore, some health-care systems offer
advanced therapies such as ECMO but lack a coordinated
local, regional,or national referral protocol.
Given the practical constraints on substantially
increasing the global availability of ECMO services in
the next few months, it is important to emphasise the
other evidence-based treatment options that can be
provided for patients with severe ARDS from COVID-19
(figure).2
Before endotracheal intubation, it is important
to consider a trial of high-flow nasal oxygen for patients
with moderately severe hypoxaemia. This procedure
might avoid the need for intubation and mechanical
ventilation because it provides high concentrations
of humidified oxygen, low levels of positive end-
expiratory pressure, and can facilitate the elimination
of carbon dioxide.4
WHO guidelines support the use of
high-flow nasal oxygen in some patients, but they urge
close monitoring for clinical deterioration that could
result in the need for emergent intubations because
such procedures might increase the risk of infection to
health-care workers.5
For patients with COVID-19 who require endotracheal
intubation, use of low tidal volume (6 mL/kg per
predicted bodyweight) with a plateau airway pressure of
less than 30 cm H2O, and increasing the respiratory rate
to 35 breaths per min as needed, is the mainstay of lung-
protective ventilation. If the hypoxaemia progresses to
a PaO2:FiO2 ratioof less than 100–150 mm Hg, there are
several therapeutic options. The level of positive end-
expiratory pressure can be increased by 2–3 cm H2O every
15–30 minto improveoxygen saturationto 88–90%,with
the goal of maintaining a plateau airway pressure of less
than 30 cm H2O. Lower driving pressures (plateau airway
pressure minus positive end-expiratory pressure) with
a target of 13–15 cm H2O can also be used. If the patient
is not responding to adjustment of the level of positive
end-expiratory pressure, additional strategies might
stabilise them. Recruitment manoeuvres probably have
little value,6
but moderate pressures of approximately
30 cm H2O for 20–30 s can be applied in the presence of
a physician to monitor haemodynamics. If there is no
improvement in oxygenation or driving pressure, or if
the patient develops hypotension or barotrauma, the
recruitment manoeuvres should be discontinued. If
there is considerable dyssynchrony with positive pressure
ventilation, accompanied by increased plateau airway
pressures and refractory hypoxaemia, then deep sedation
should be used followed by prompt institution of
neuromuscular blockade with cisatracurium. Additionally,
Lancet Respir Med 2020
Published Online
March 20, 2020
https://doi.org/10.1016/
S2213-2600(20)30127-2
See Online/Health-care
Development
https://doi.org/10.1016/
S2213-2600(20)30121-1
Therapy Implementation
High-flow nasal oxygen Might prevent or delay the need for intubation
Tidal volume Use 6 mL/kg per predicted bodyweight
(can reduce to 4 mL/kg per predicted bodyweight)
Plateau airway pressure Maintain at <30 cm H20 if possible
Positive end-expiratory pressure Consider moderate to high levels if needed
Recruitment manoeuvres Little value
Neuromuscular blockade For ventilator dyssynchrony, increased airway pressure, hypoxaemia
Prone positioning For worsening hypoxaemia, PaO2:FiO2 <100–150 mm Hg
Inhaled NO Use 5–20 ppm
Fluid management Aim for negative fluid balance of 0·5–1·0 L per day
Renal replacement therapy For oliguric renal failure, acid-base management, negative fluid balance
Antibiotics For secondary bacterial infections
Glucocorticoids Not recommended
Extracorporeal membrane oxygenation Use EOLIA trial criteria3
Figure: Therapeutic options for severe acute respiratory distress syndrome relatedto coronavirus disease 2019
ppm=parts per million.
2. Comment
2 www.thelancet.com/respiratory Published online March 20, 2020 https://doi.org/10.1016/S2213-2600(20)30127-2
prone positioning should be instituted, unless there is a
specific contraindication, and can be initiated along with
the interventions alreadydescribed.
For persistent refractory hypoxaemia even with prone
positioning, neuromuscular blockade, and efforts to
optimise positive end-expiratory pressure therapy, there
are additional options. Inhaled 5–20 ppm NO might
improve oxygenation. Insertion of an oesophageal
balloon to measure transpulmonary pressures to set
an optimal positive end-expiratory pressure can be
considered in patients with moderate-to-severe obesity,
although a 2019 trial in patients with ARDS did not
show the benefit of this procedure in most patients.7
Fluid management is important to consider as a
measure to reduce pulmonary oedema.8
In the absence
of shock, fluid conservative therapy is recommended
to achieve a negative fluid balance of 0·5 to 1·0 L
per day. In the presence of shock, fluid balance might be
achieved with renal replacement therapy, especially
if there is associated acute kidney injury and oliguria.
Antibiotics should be considered since secondary
bacterial infections have been reported in patients with
COVID-19.9
Glucocorticoids should be avoided in view
of the evidence that they can be harmful in cases of viral
pneumonia and ARDS from influenza.10
Rescue therapy
with high-dose vitamin C can also be considered.11
Finally, ECMO should be considered using the inclusion
and exclusion criteria of the EOLIA trial.3
Since treatment of severe ARDS from COVID-19
is an ongoing challenge, it is important to learn
from the patients who have been treated to gain an
understanding of the disease’s epidemiology, biological
mechanisms, and the effects of new pharmacological
interventions. Currently, there are some research groups
workingto coordinate and disseminate key information,
including information on patients who have been
treated with ECMO for COVID-19, although an accurate
estimate of the number of such patients is not currently
available. The Extracorporeal Life Support Organization
is an international non-profit consortium that plans to
maintain a registry of patients to facilitate an improved
understanding of how ECMO is being used for patients
with COVID-19.
MAM reports grants from the National Institutes of Health—the National Heart,
Lung and Blood Institute, the US Food and Drug Administration, the US
Department of Defense, Bayer Pharmaceuticals, Genentech-Roche, and personal
fees from Gen1e Life Sciences, outside of the submitted work. JMA has done
been part of the electronic medical records committee of the Society of Critical
Care Medicine, outside of the submitted work. JEG declares no competing
interests.
*Michael A Matthay, J Matthew Aldrich, Jeffrey E Gotts
michael.matthay@ucsf.edu
Department of Medicine, Department of Anesthesia (MAM, JMA, JEG), and
Cardiovascular Research Institute (MAM),The University of California, San
Francisco, CA 94158, USA
1 Ramanathan K, Antognini D, Combes A, et al. Planning and provision of
ECMO services for severe ARDS during the COVID-19 pandemic and other
outbreaks of emerging infectious diseases. Lancet Respir Med 2020;
published online March 20. https://doi.org/10.1016/S2213-
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