At the risk of info overload I found this interesting. It goes in to more detail but I will spare you
SUMMARY AND RECOMMENDATIONS
●Among patients hospitalized with coronavirus disease 2019 (COVID-19), up to one-quarter require intensive care unit (ICU) admission. (See 'Introduction' above and 'Epidemiology' above.)
●Profound hypoxemic respiratory failure from acute respiratory distress syndrome (ARDS) is the dominant finding in critically ill patients. Common complications include acute kidney injury (AKI), elevated liver enzymes, and the late development of cardiac injury, including sudden cardiac death. Sepsis, shock, and multi-organ failure are less common. (See 'Clinical features in critically ill patients' above.)
●For most critically ill patients with COVID-19, we prefer the lowest possible fraction of inspired oxygen (FiO2) necessary to meet oxygenation goals, ideally targeting a peripheral oxygen saturation between 90 and 96 percent. (See 'Respiratory care of the nonintubated patient' above and 'Oxygenation targets' above and 'Low flow oxygen' above.)
•The use of high-flow oxygen via nasal cannulae (HFNC) and noninvasive ventilation (NIV) is controversial based on infection control concerns and the frequent need for mechanical ventilation despite these measures. The decision to initiate noninvasive modalities requires balancing the risks and benefits to the patient, the risk of exposure to healthcare workers, and best use of resources; this approach should be reassessed as new data becomes available. (See 'Patients with higher oxygen requirements' above.)
•In patients with COVID-19 who have acute hypoxemic respiratory failure and higher oxygen needs than low flow oxygen can provide, we suggest selective use of noninvasive measures be used rather than routinely proceeding directly to intubation (Grade 2C). As an example we might trial HFNC in younger patients without comorbidities who can tolerate nasal cannulae. In contrast, we may proceed directly to early intubation in patients at higher risk (eg, elderly patients and patients with comorbidities or risk factors for progression).
•Among the noninvasive modalities we suggest HFNC rather than NIV (Grade 2C). Our preference for HFNC is based upon limited and inconsistent data, which, on balance, favors HFNC compared with NIV in HFNC in patients with non-COVID-19-related acute hypoxemic respiratory failure. NIV via a full face mask (with a good seal) may be appropriate in patients with indications that have proven efficacy including acute hypercapnic respiratory failure from an acute exacerbation of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and sleep disordered breathing. (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications", section on 'Medical patients with severe hypoxemic respiratory failure' and "Noninvasive ventilation in acute respiratory failure in adults", section on 'Patient selection'.).
•For patients with COVID-19 who receive HFNC or NIV, vigilant monitoring is warranted for progression with frequent clinical and arterial blood gas evaluation every one to two hours to ensure efficacy and safe ventilation. The threshold to intubate such patients should be low.
●For critically ill patients with COVID-19, intubation should not be delayed until the patient acutely decompensates since this is potentially harmful to both the patient and healthcare workers. We have a low threshold to intubate those who have (see 'Timing' above):
•Rapid progression over a few hours
•Failure to improve despite HFNC >40 L/min and FiO2 >0.6
•Development of hypercapnia
•Hemodynamic instability or multiorgan failure
●Intubation is a high risk procedure for aerosol dispersion in patients with COVID-19 and attention should be paid to donning full personal protective equipment (PPE) with airborne precautions (figure 1 and figure 2) as well using equipment that minimizes dispersion (eg, video laryngoscopy) and the development of protocols for the procedure (eg, check lists) (figure 5). (See 'Precautions' above and "Safety in the operating room", section on 'COVID-19'.)
●We use low tidal volume ventilation (LTVV) targeting ≤6 mL/kg predicted body weight (PBW) (range 4 to 8 mL/kg PBW (table 1 and table 2)) that targets a plateau pressure ≤30 cm H2O and applies positive end-expiratory pressure (PEEP) according to the strategy outlined in the table (table 3). For patients with COVID-19 that fail LTVV, prone ventilation is the preferred next step (table 4 and table 5). (See 'Ventilator management of acute respiratory distress syndrome' above and "Ventilator management strategies for adults with acute respiratory distress syndrome" and "Prone ventilation for adult patients with acute respiratory distress syndrome" and "Extracorporeal membrane oxygenation (ECMO) in adults".)
●Several procedures, including the collection of respiratory specimens, bronchoscopy, extubation, and cardiopulmonary resuscitation are aerosol-generating and should be avoided or minimized, if possible. All procedures should be grouped when possible. (See 'Interventions' above.)
●Patients with COVID-19 pneumonia who are mechanically ventilated for ARDS should receive the usual daily surveillance, and supportive care including conservative fluid management (unless patients have sepsis or volume depletion). Measurement of surveillance cardiac troponins and a low threshold to perform transthoracic echocardiography is appropriate for the early detection of cardiac injury. (See 'Supportive care' above and 'Surveillance' above.)
•In critically ill patients with COVID-19-induced ARDS who do not have a specific indication (eg, acute bronchospasm or refractory septic shock), we suggest not administering glucocorticoids (Grade 2C). The rationale for not administering glucocorticoids in this population is that the data supporting any benefit in the non-COVD-19 population did not include a sufficient proportion of patients with viral pneumonia to inform safety and that data in patients with ARDS due to viral pneumonia (eg, severe acute respiratory syndrome [SARS], Middle East respiratory syndrome [MERS], influenza) suggested harm. (See "Acute respiratory distress syndrome: Supportive care and oxygenation in adults", section on 'Glucocorticoids'.)
•For acute bronchodilation, we prefer the use of in-line metered dose inhalers (MDIs) rather than administration via a standard jet or vibrating mesh nebulizer due to the lower risk of aerosolization associated with MDIs. Individual institutions should work with their pharmacy regarding compassionate use of investigational medications and trial enrollment. We suggest the development of protocols by individual ICUs for the off-label use of investigational agents. (See 'Nebulized medication' above and "Coronavirus disease 2019 (COVID-19)", section on 'Investigational approaches'.)
●For patients with COVID-19 pneumonia who develop ARDS, the prognosis is poor with mortality ranging from 52 to 67 percent. The highest rates of death occur in those ≥64 years. (See 'Prognosis' above.)
●A greater level of anxiety and trauma among patients and families should be anticipated and combatted with clear communication strategies and early palliative care involvement. (See 'End of life issues' above.)
●Several measures should be adopted to accommodate a surge in COVID-19 cases including included expanding ICU care into non-ICU spaces, utilizing non-critical care trained staff to participate in delivering critical care, and innovative approaches to obtain, conserve, and increase the efficiency of physical equipment (eg, personal protective equipment and mechanical ventilators). (See 'Surge capacity and scarce resource allocation' above.)
