BOSTON MEDICAL CENTER MICU AND PULMONARY COVID-19 BEST PRACTICES

This document was developed for internal use at Boston Medical Center. These are not recommendations nor are they guidance for use outside of BMC. Please check that you have the latest version of this document here. The latest versions of BMC algorithms and policies can be found here. Questions/concerns should be directed to Dr. Allan Walkey ()

RAPID MANAGEMENT OVERVIEW

CLINICAL COURSE PRIMER

SARS-CoV-2 (the virus that causes COVID-19) is a coronavirus. These are large, enveloped, single-strand RNA viruses. Summary of available data:

Incubation period

  • 4 days (range 2-7)

Typical symptoms

  • Fever (77-90%)
  • Cough (70-79%)
  • Dyspnea (3-50%)
  • Anosmia (30%)
  • Sore throat (14%)
  • Nasal congestion (5%)
  • Diarrhea (4%)

Severity

  • 80% of patients with mild symptoms
  • 14% with severe disease
  • 5% with critical disease: require ICU for ARDS (20-30% of hospitalized patients)
  • Mortality: Age >60 years 3.6%, 70-79 years 8%, >80 years 14.8%, Mechanical ventilation 40% Chinese Center of Disease Control

Timeline

  • Hospitalized ~8 days after exposure
  • Respiratory failure ~12 days after exposure, 10 days after onset of dyspnea (late but rapid deterioration is characteristic feature)
  • Cardiac injury ~17 days (increased incidence of cardiac arrest, cardiomyopathy)
    -Viral shedding ~20 days after exposure

Lab abnormalities

  • Lymphopenia (80-90%)
  • CRP >10mg/l (61%) – associated with poor survival
  • PCT <0.5 (94%)
  • ALT/AST>40 (22%)
  • Elevated ferritin, LDH, and troponin

TIPS FOR WORKING IN COVID-19 ICUs

  • The most up to date BMC policy on PPE, plus donning and doffing videos is located here
  • Watch the Donning/Doffing video multiple times
  • ALWAYS take time to apply appropriate PPE, even in emergency situations
  • Hospital scubs should be worn by all staff in the ICU. Scrubs are avialable in the scrub machine between the MICU and CCU and in the nurse manager’s office on MICU A at the beginning of every shift. Please contact Rob Elloyan, , to obtain access to a Scrub Card. Place scrubs in laundry bins at the end of each shift.
  • BMC command center: 617-414-6860
  • Working Well Clinic
  • If you become sick for for any reason feel you cannot work an assigned shift, please active the backup system by contacting Felicia Chen (faculty), Chris Reardon (fellows), or the chief residents (house staff)

Personal Care Checklist

  • Have you been fit tested for N-95? Have you shaved?
  • Have you received your flu vaccination?
  • Are you sick?
  • Hungry? Thirsty? Empty bladder?
  • Have you removed all jewelry?
  • All items (stethoscope, badge, pager, phone, pen, papers) removed from pockets?
  • Cell phone: consider bringing a transparent bag to store and avoid contaminating your cell phone.
  • Shoes impermeable to liquids?
  • Scrubs and underwear only as bottom layer? (Scrubs are available MICU A in the charge nurse office)
  • Hair pulled back?

Staying Clean in the Room

  • Disposable Stethoscope use
    • Enter the room, immediately put hand sanitizer on your glove and clean stethoscope. (Do at the beginning, rather than after using it because it’s hard to be sure you’re not just continually recontaminating it with your dirty gloves)
  • Putting on and taking off the stethoscope
    • It’s tricky with the large face shields. Grab the scope at the base of the Y to put it in your ears. To remove it, trace your hands up from the bell of the scope to the base of the Y and spread the prongs that way to remove it
  • Use the interpreter iPad, rather than phone
    • Patients use the phone

INITIAL ICU EVALUATION

SARS‐CoV‐2 (COVID‐19) and Comprehensive Respiratory Panel Testing

  • BMC now has in-house COVID-19 testing with expected turnaround time to be 6-8 hours after receipt by the laboratory
  • Following hospital guidelines, use the EPIC COVID-19 Order Panel with the preferred/high risk testing selected to test for both SARS‐CoV‐2 (COVID‐19) and the Comprehensive Respiratory Panel from the same nasopharyngeal sampling.
  • Since nasopharyngeal swabs often generate a strong cough reflex, enhanced PPE are recommended.
  • For safety reasons, specimens from a patient with suspected or documented COVID-19 should not be submitted for viral culture.

Laboratory Testing of Patients with Severe COVID-19

Severe COVID-19 is defined as respiratory failure (e.g. dyspnea, hypoxia, or >50% lung involvement on imaging within 24-48 hours) or critical ilness (e.g. shock, or multi-organ dysfunction)

COVID-19 ancillary testing

  • Chemistry panel
  • LFTs including albumin
  • CBC with differential (lymphopenia most common)
  • Procalcitonin (normal in 95% of patients; more likely to be elevated in ICU patients)
  • Ferritin
  • Triglycerides
  • Fibrinogen
  • CRP
  • ESR
  • Troponin
  • LDH
  • CPK
  • D-dimer
  • PT

Rationale

  • Evidence suggests that a subgroup of patients with severe COVID-19 develop increased inflammation that often precedes clinical decline.
  • Consider regular repeat testing of LFTs, procalcitonin, ferritin, triglycerides, fibrinogen, CRP, ESR, LDH, d-dimer, and troponin to track disease severity, especially with change in clinical status.
  • Check troponin/EKG in a deteriorating patient to assess for cardiomyopathy, and conduction disturbance. Higher than expected cardiovascular deaths (VT/VF, asystole) have been seen in COVID-19 patients.

Discontinuation of precautions after a negative test

  • To remove a COVID YELLOW or RED banner: The Attending Provider must fill out the attestation form from the link on the banner itself. You no longer need to contact Infection Control. Then, Bed Control will remove the banner between 7A to 11P weekdays and 7A to 7P on weekends. Note: A banner cannot be flagged for removal if a COVID test is currently in process in the lab

Imaging

  • Portable chest x-rays are sufficient in most cases for assessing the patient’s lung parenchyma
    • Bilateral patchy infiltrates are most common (may evolve rapidly)
  • Lung POC ultrasound Peng et al.
    • Pleural line thickening and irregularity
    • B-lines
    • Consolidations
    • A-lines appear in recovery phase
    • Pleural effusions are uncommon and alternative diagnoses should be considered
  • Routine Chest CT is NOT recommended
    • Common findings include ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia Kanne et al.
      • CT Chest should only be considered in specific cases where there is diagnostic uncertainty and/or it will lead to changes in clinical management when other diagnostic methods are unreliable. CT Chest can overwhelm resources (e.g., need for transport, cleaning of CT scan suite, nursing effort), and increase risk of exposure. CTPA should be reserved for situations where the results will change management and it is safe to transport the patient (e.g., a hemodynamically stable patient on empiric anticoagulation for possible PE, but with negative extremity dopplers)

Empiric Antibiotic Guidance

Bronchoscopy

  • Bronchoscopy is NOT recommended or necessary for the purpose of ruling COVID-19 in or out and should be avoided to minimize risk of aerosolization.
  • Bronchoscopy should only be done if it will change clinical management and should be completed in a negative pressure room.

ORGAN DYSFUNCTION MANAGEMENT

Supportive care, and first DO NO HARM

Acute Respiratory Failure

  • Use a conservative fluid approach, use vasopressors over large volume (>30cc/kg) initial resuscitation FACTT Algorithm
  • Nasal cannula up to 6Lpm, then nasal pedant up to 15L, or NRB up to goal SpO2 sat >90% after initially stabilized
  • Consider high flow nasal cannula (HFNC) with surgical mask to reduce aerosol if requiring NRB or escalating pendant. Heated humidified air improves patient comfort, muco-cilliary elevator clearance, and high flows enable higher oxygen delivery without dilution from room air entrainment and PEEP at 1ccH2O per 10lpm flow (with a closed mouth).
  • Non-invasive positive pressure ventilation is generally not indicated in pure hypoxemic respiratory failure.
  • During transport, use nasal cannula/pendant for oxygen administration or NRB if additional oxygen is needed
  • Patients being transported with oxygen should wear droplet masks during transport over oxygen tubing
  • Note: NRB mask O2 flow rate should not be titrated. Decreasing the NRB O2 flow rate increases the risk of reinhalation of CO2.
  • If inability to oxygenate (e.g., SpO2 sat <90%) but no signs of hypoxic organ dysfunction (i.e., patient is alert, with intact mental status, speaking full sentences, near normal work of breathing, no significant non-respiratory dysfunction, normal lactate), then patient likely needs critical care consultation and ICU-level monitoring, but not necessarily intubation for asymptomatic hypoxemia.
  • Consider suggesting awake prone position for patients with receiving >6 LPM of supplemental oxygen
  • If inability to ventilate (arterial pH <7.3 with PaCO2 > 50), and/or if patient has signs of respiratory distress (accessory muscle use, abdominal paroxysmal breathing, altered mental status, shock), then strongly consider CONTROLLED ELECTIVE intubation
    • Make sure anesthesia and respiratory therapy are aware pt is COVID-19 + or PUI
      • Clinician hand don appropriate PPE
      • Ensure utilization of appropriate filters during bag mask ventilation (e.g. white bacterial/viral ENVE filter between the bag and the mask) and mechanical ventilation (e.g. PALL or N100 HEPA filters)
    • Consider central line (avoid RIJ to leave for renal replacement therapy access) and a-line (if frequent abg) at same time as intubation to minimize patient contacts

ARDS Management

  • The most common severe complication of COVID-19 is ARDS
  • ARDS Definition: Bilateral infiltrates PaO2/FiO2 <300 or SatO2/FiO2 <315, PEEP 5 or more, acute onset, not explained by heart failure
    • Preliminary data suggest that 15-20% of hospitalized patients will develop ARDS Guan et al. Wang et al.
    • Time from illness onset to ARDS 12 days
  • Mainstay of ARDS treatment is mechanical ventilation designed to not cause further injury
  • We recommend ventilator settings that target the following
    • PaO2 55-80 is historical standard and a reasonable target
    • Good enough ventilation (pH >7.15)
    • Initial settings
      • Volume Assist Control with tidal volume 4-8cc/kg Predicted body weight
      • 5-10 PEEP, may need titration to 10-15 (see above ARDSnet table)
        • evaluate for improvement in oxygen at risk for hypotension with PEEP increases
      • RR enough to meet estimated pre-intubation minute ventilation (MV = TV * RR, goal 10-15 for sick patients, then readjust, usually will need RR 25-30 to start)
      • Goal plateau pressure <30
    • In patients requiring escalating sedative infusions for ventilator dys-synchrony, consider use of Airway Pressure Release Ventilation (APRV), which may facilitate ventilator synchrony and has been shown to lower sedative requirements/avoid need for neuromuscular blockade
      • Caution should be taken for use of APRV in patients with strong respiratory efforts generating large trans-alveolar pressures (i.e., Inspiratory Pressure [Phigh]-respiratory effort negative pressure may cause additional lung injury).
  • ARDS adjunctive therapies
    • Prone position Guerin et al. (BMC Protocol BMC login required)
      • Recommend if P/F <150 for 12 hours or worsening oxygenation after intubation without other cause.
      • Prone position for 12-16 hours daily provides mortality benefit through reduced lung injury
      • Positive criteria for stopping prone treatment:
        • PaO2:FiO2 ratio of ≥150 mm Hg with PEEP of ≤10 and an FiO2 of ≤0.6 in the supine position at least 4 hours after the end of the last prone session
      • Negative criteria for stopping prone treatment (either criteria is sufficient alone to discontinue prone treatment):
        • Decrease in the PaO2:FiO2 ratio of more than 20% relative to the ratio in the supine position, before two consecutive prone sessions
        • Complications occurring during a prone session and leading to its immediate interruption (e.g., extubation, main-stem bronchus intubation, endotracheal tube obstruction, hemotpysis, hemodynamic instability, worsening hypoxemia, cardiac arrest, bardycardia)
        • NOTE: prone position patients do NOT routinely require neuromuscular blockade
    • Inhaled NO/Epoprostenol
      • adjunctive therapy designed to improve oxygenation. No known mortality benefit. It complicates routine vent FiO2 changes, so recommend only for life-threatening hypoxemia, e.g., consider if P/F <100, strongly consider if P/F<60. Watch for renal failure complication. Epoprostenol use is now considered minimal risk for virus aerosolization and is available for use in COVID-19 patients on critical care ventilators.
        • Patients who potentially meet indications for inhaled epoprostenol should first be trialed on inhaled NO to test for responsiveness based on PaO2 or SaO2 (see appenix for trial procedure)
    • Neuromuscular blockade
      • As needed for ventilator dyssynchrony and high respiratory drive resulting in injurious tidal volumes, airway pressures, double-triggering, breath stacking, or inability to oxygenate or ventilate
      • Analgesia, sedation, and amnesia are absolutely necessary PRIOR to inducing paralysis
      • See SEDATION/ANALGESIA/PARALYSIS section for NMB choice and dosing
    • ECMO: patients with severe ARDS should be considered for ECMO referral, especially if there is minimal response in oxygenation or driving pressure to prone positioning. Resources for ECMO REFERRAL can be found in the appendix.

Corticosteroids

  • RECOVERY trial showed that mortality is reduced with dexamethasone 6mg daily in hospitalized patients with COVID-19 who require oxygen supplementation (RR 0.80, 95% CI 0.67-0.96, p=0.002) or mechanical ventilation (0.65, 95% CI 0.48-0.88, p=0.0003), but not for patients who do not require oxygen (RR 1.22, 95% CI 0.86-1.75).
    ## Weaning and Extubation Patients with improvement in the reason that they required mechanical ventilation should be considered for a weaning trial. In addition to clinical improvement, guidelines for consideration of a weaning trial include:
  • Ability to initiate own breaths
  • O2 saturation >90% on 40% oxygen or less, or PaO2/FiO2 >150
  • pH>7.25
  • Hemodynamically stable on low dose, reliably down-titrating, or no vasopressors
  • Minute ventilation requirements not excessive (e.g, <12Lpm, RR <30)
  • Mental status with ability to protect airway (eg., GCS>8, but not a strict criterion) or not cause self-harm due to agitation
  • Lack of excessive respiratory secretions (eg q2 hour secretion suctioning requirement)

Spontaneous Awakening

Once patients are deemed ready for weaning, sedatives should be minimized/held and a spontaneous breathing trial (SBT) can be attempted.

Spontaneous Breathing Trial

A SBT switches the patient to a pressure support mode of mechanical ventilation with low levels of pressure support (5 ccH20) and PEEP (5) and allows them to breathe mostly on their own. During the COVID-19 pandemic, BMC clinicians have noticed that more patients than usual are being re-intubated after passing an SBT on 5/5. When patients have completed ~2 hours of an SBT and still meet the criteria for consideration of a weaning trial (stable respiratory status, non-copious secretions, and sufficient mental status), then consider the patient for extubation.

Risks and benefits of a cuff leak test and empiric corticosteroids prior to extubation

Given the reported high incidence of post-extubation stridor in patients with COVID-19, the imperfect sensitivity of cuff leak tests in predicting re-intubation, and risk of aerosolization during cuff leak test, we recommend empiric treatment with corticosteroids (methylprednisolone IV 40mg if not already receiving dexamethasone) 12 hours prior to planned extubation if possible, with re-dose 20mg 4-6 hours prior to extubation, but can also consider extubation 4-6 hours after first steroid dose, especially in patients at lower risk of laryngeal edema (men, ETT<7.5, alert, intact mental status). It takes 4-8 hours for steroids to reduce laryngeal edema. Use of steroids prior to extubation has been shown to reduce risks of re-intubation by at least 50% across multiple randomized trials, without a need for cuff leak test, without need for cuff leak test.

Extubaton procedure recommendations

  1. Patients who are nearing readiness for extubation should receive a dose of methlyprednisolone 40mg IV 4-6 hours prior to planned extubation. Max dose 80mg if extubation is delayed
  2. For patients who have been receiving MDI bronchodilators, administer dose approximately 15 minutes prior to extubation
  3. Explain sequence of events to patient and the preference that they swallow oral secretions if possible
  4. Place oxygen mask over patient’s forehead at 10lpm
  5. Place surgical mask over oxygen mask
  6. Suction any secretions above cuff
  7. Extubate
  8. Quickly slide oxygen mask and covering surgical mask into place over mouth and nose
  9. Do not encourage coughing

Shock Management

  • Evaluate for underlying cause of shock (septic, cardiogenic, obstructive, adrenal insufficiency) – TTE, capillary refill, central venous O2 sat
  • Preferential use of vasopressors rather than large volume fluid resuscitation to avoid exacerbating ARDS
  • Initial vasopressor of choice norepinephrine, 1-30 mcg/min
    • Secondary vasopressor vasopressin 0.4 units if distributive shock
    • Consider epinephrine, or consideration of milrinone, dobutamine if cardiogenic component, cardiology consult
  • Goal MAP 60 is associated with fewer complications than 65, but with similar outcomes
  • Sedation (spontaneous awakening and breathing trials), Nutrition, Glucose, DVT-GI Prophylaxis all managed per standard ICU protocols.

Stress Ulcer Prophylaxis (SUP)

Shortages of H2 blockers and Proton pump inhibitors are common during Covid-19. While SUP does reduce clinically important GI bleeding (0.58 [0.40–0.86]), SUP does not reduce mortality, even in high risk patients (RR1.02 [0.91–1.13], Krag et al. 2020). However, given blood shortages, we want to limit bleeding that requires transfusion. Thus, to preserve our blood supply, pharmacological SUP should be used for patients with the highest risk of GI bleeding, who include patients meeting the following criteria:

  • History of GI ulceration or GI bleeding within the past year
  • Mechanical ventilation, and any of the following:
    • Renal replacement therapy
    • Thrombocytopenia (platelet count <50,000 per m3)
    • Coagulopathy (INR >1.5, PTT >2 times the control value)
    • Glucocorticoid therapy (more than 250 mg hydrocortisone or the equivalent); or non-steroidal anti-inflammatory or anti-platelet agents
    • Vasopressors
    • Traumatic brain injury, traumatic spinal cord injury, or burn injury
  • Clinicians may also consider observational evidence that enteral nutrition is associated with decreased risk of GIB (RR 0.30 [0.13-0.67], Cook et al. 1999) and reasonably opt to discontinue SUP among patients who are receiving enteral nutrition.

Anticoagulation during COVID-19

COVID-19 infection may increase the risk of venous and arterial thromboses. Below is a suggested approach for anticoagulation in COVID-19 patients developed by a multi-disciplinary group at BMC. When instituting anticoagulation, consider the risk of clinically significant bleeding.

SEDATION/ANALGESIA/PARALYSIS

During the covid-19 pandemic, medications commonly used for analgesia, sedation, and paralysis at BMC may not be readily available (specifically continuous infusion sedatives). This section outlines the (1) various pharmacologic options to provide analgesia, sedation, and paralysis to our ventilated patients in the ICU, (2) proposes a practical framework that uses scheduled enteral or IV push medications to lessen the dose of continuous infusions to extend duration whenever clinically feasible, and (3) creates a fluid resource for clinicians that evolves based on currently available medications. Please see the appendix for a diagram of this process.

Sedatives

General Approach

Typically, patients should be provided the lowest level of sedation necessary to be comfortable and synchronous with the ventilator. For most agents (excluding lorazepam) use a continuous infusion for the first 18-24 hours after intubation to assess overall sedation needs.

Following ~24 hours of continuous infusion to evaluate sedative requirements:

  1. Initiate scheduled NG/OG or IV push sedation, if patient requires continuous infusion rates above thresholds as detailed below under “Specific Medications-Sedatives”
  2. Defer initiation of scheduled NG/OG or IV push sedation if patient does not meet threshold criteria under “Specific Medications-Sedatives”, or if there is a plan to attempt extubation in the next 24-48 hours.
  3. Discontinue scheduled NG/OG sedatives 12 hours before any planned extubation (if dexmedetomidine or ketamine not already started and available, consider initiating to in an effort to minimize benzodiazepine use and aid in extubation as these medication do not decrease respiratory drive).

Sedative Medication Options

Propofol

First line

  1. Initiate continuous infusion at 10 mcg/kg/min per Epic default order
  2. If patient requires rate > 30mcg/kg/min initiate lorazepam 2mg NG/OG/IV push q6hrs or 64.8 mg NG/OG phenobarbital q8hr
  3. If patient requires > 40mcg/kg/min then increase dose or frequency of NG/OG/IV push lorazepam/phenobarbital
  4. Monitor: triglycerides q48-72 hours and reduce doses when triglycerides approach 500- 600 mg/dL (consider repeating if triglyceride levels are unexpectedly high as the lab may have been drawn off of the line through which propofol was being administered)

Midazolam

Second line

  1. Initiate continuous infusion at 2mg/hr per Epic default order
  2. If patient requires rate > 5mg/hr for > 48 hours then start NG/OG lorazepam at 2mg NG/OG q6hrs or phenobarbital at 64.8 mg NG/OG q8hrs
  3. If patient requires rate > 10 mg/hr for > 48 hours increase the dose or frequency of NG/OG lorazepam or phenobarbital
  4. Monitor: Caution active metabolites are not cleared during renal insufficiency which may accumulate and cause excess sedation

Lorazepam

Third line infusion. First line NG/OG supplement and intermittent IV bolus.

  1. Following intubation administer 2mg IV push to assess patient response to lorazepam.
    • If patients responds appropriately (Riker <4 for at least 30 mins) to single 2mg dose, consider 2mg q6h IV push dosing or initiation of continuous infusion at 0.5mg/hr
    • If during initial assessment (before leaving room after getting the patient settled) the patient requires >2 doses of IV push, then start continuous infusion at 1mg/hr
    • If patient requires rate > 2mg/hr for > 48 hours initiate lorazepam 2mg NG/OG q6hrs or 64.8 mg NG/OG phenobarbital q8hr
  2. In patients with CrCl < 30 do not exceed continuous infusion 3mg/hr (~1mg/kg/d) due to risk of propylene glycol toxicity (due to vehicle of continuous infusion, not a concern for enteral lorazepam).
    • Recommend checking serum osm (to assess for osmolar gap) daily for any patient on continuous infusion > 48hrs or with CrCl < 30
    • Recommend checking serum osm (to assess for osmolar gap) for any patient who develops new anion gap or acute kidney injury while on lorazepam infusion
      1. If osmolar gap > 10, reduce parental lorazepam doses as these patients are at higher risk of propylene glycol toxicity

Dexmedetomidine

First line adjunct.

  1. In general, dexmedetomidine is unlikely to provide deep levels of sedation. Therefore, in the current climate we recommend its use mainly as a 2nd line adjunct to other sedatives, or as a 24-48 hour bridge to wean benzodiazepines (infusion, scheduled IV push/NG/OG) to facilitate extubation.
  2. Monitor: bradycardia

Ketamine

Second line adjunct.

  1. Ketamine has both sedative- and analgesic-sparing properties
  2. Consider use in patients requiring high dose continuous infusion propofol, or any continuous benzodiazepines, to decrease or eliminate benzodiazepine requirements
  3. Initiate at 0.1mg/kg/hr; do not exceed 1.2mg/kg/min as this is when patients begin to dissociate (higher doses may be used to treat refractory status epilepticus, status asthmaticus, or in patients failing high doses of propofol/benzodiazepines and requiring paralytics) Ketamine is unlikely to replace benzodiazepines when using for vent synchrony. Ketamine has shown to increase tracheal secretions, caution in patients who have excess secretions or have mucus plugging (consider alternative agent)

Phenobarbital

Third line adjunct.

  1. For sedation following intubation, consider dosing of 260 mg IV x1, followed by 130 mg IV q6h
  2. For assistance in weaning off a benzodiazepine infusion, consider starting dose of 130 mg IV q6h
  3. If concerned for over sedation, recommend checking a phenobarbital level and hold further doses until level <30 mcg/mL. NOT to be used as monotherapy sedation for paralysis

Additional considerations

For patients requiring sedatives for increased agitation, consider scheduled neuroleptics and anti-epileptic ‘mood stabilizers’ as additional adjunctive medications, especially as continuous infusions are weaned. For patients with delirium while using continuous infusion benzodiazepines, consult with ICU pharmacist regarding the potential use of phenobarbital to completely replace benzos. Note, neither of the below medications are likely to benefit patients requiring high doses of sedatives for vent dyssynchrony.

  1. Quetiapine 50mg nightly (ICU delirium) or 25mg q6h (ATC agitation)
    • Check daily QTc if used as an adjunct, and avoid particularly if used with additional QTc-prolonging medications (hydroxychloroquine, azithromycin, methadone). See appendix for a reasonable approach to QTc prolongation when using multiple QTc prolonging medications
  2. Valproate 250mg IV q6h

Table of Adjunctive Therapies

Potentially Sedative-Conserving Ventilator Strategies

  • In patients requiring escalating sedative infusions for ventilator dys-synchrony, consider use of Airway Pressure Release Ventilation (APRV), which may facilitate ventilator synchrony and has been shown to lower sedative requirements/avoid need for neuromuscular blockade
  • Caution should be taken for use of APRV in patients with strong respiratory efforts generating large trans-alveolar pressures (i.e., Inspiratory Pressure [Phigh]-respiratory effort negative pressure may cause additional lung injury).

Analgesia

General Approach

Initiate all patients on continuous infusion of analgesia following intubation (i.e, the analagosedative approach); if a patient can be managed on q6h IVP analgesics, that is preferred, however, uncommon. Most patients will require a continuous infusion.

Following 18-24 hours of continious infusion to evaluate analgesia requirements:

  1. Initiate scheduled NG/OG analgesia if patient requires continuous infusion rates above thresholds as detailed below under “Specific Medications-Opioids”.
  2. Defer initiation of scheduled NG/OG analgesia if patient does not meet criteria, or if there is a plan to attempt extubation in the next 24-48 hours.
  3. Discontinue scheduled NG/OG analgesia 12 hours before any planned extubation to facilitate a successful SAT/SBT (see recommendations for dexmedetomidine and ketamine below).

Analgesia Medication Options

Fentanyl

First line. UPDATE: Fentanyl has been loaded in the ICU pyxis machines as of 4/21/2020 and is available for use. The recommendation is to use for ~48hr to determine clinical course. If a patient doesn’t look like they will extubate soon, then change back to dilaudid.

  1. Initiate continuous infusion at 12.5-50mcg/hr per Epic default order
  2. If patient requires rate > 150mcg/hr initiate hydromorphone 4mg NG/OG q6h
  3. If patient requires rate > 200mcg/hr then increase dose or frequency of scheduled NG/OT hydromorphone

Hydromorphone

Use if fentanyl on shortage.

  1. Initiate continuous infusion 0.25mg/hr per Epic default order
  2. If patient requires rate > 1mg/hr initiate hydromorphone 4mg NG/OG q6h
  3. If patient requires rate > 2mg/hr then increase dose or frequency of scheduled NG/OG hydromorphone
  4. Hydromorphone is hepatically metabolized. In patients with moderate to severe liver dysfunction consider enteral dose reductions of 25%-50%

Neuromuscular Blockade

A subset of patients with severe disease from COVID-19 may benefit from NMB. These patients must be receiving adequate sedation defined as: Riker sedation agitation scale (SAS) < 2 prior to initiation of paralytic agents, and then titrated to sedation level of 50-70 on Bispectral index monitoring (BIS monitoring) during period of paralysis. Note: it may be challenging to achieve this level of sedation as medication shortages arise during the COVID-19 pandemic. If deep sedation is unable to be achieved, NMB is unfortunately not possible.

Indications for NMB

  1. Severe ARDS in accordance with Berlin criteria, but specifically defined as: PaO2:FiO2 < 150 after at least 12 hours of mechanical ventilation using FiO2 > 0.6 and PEEP > 5

AND

  1. Ventilator dys-synchrony causing high plateau pressures (>30cm H2O) or injurious tidal volumes (TV >8cc/kg IBW)
    OR
  2. Ventilator dys-synchrony causing hypoxemia

NOTE: Patients in prone position do not necessarily require continuous neuromuscular blockage and need for NMB should be assessed individually based on ventilator synchrony.

Approach to NMB

While the majority of studies assessing benefit of NMB in ARDS use a continuous infusion strategy, the medication shortages occurring due to the COVID-19 pandemic requires an approach that also considers maximizing our medication supply. Therefore, in patients that meet the above criteria for NMB, use the following strategy related to dosing:

  1. Administer single IV push dose of paralytic, with dosing detailed below in specific medications-NMB
  2. Assess for clinical effect at 30-60 minutes after administration of paralytic
    1. If favorable response (i.e., a safer plateau pressure or tidal volumes, improved oxygenation), then proceed to step 3
    2. If no obvious response, then proceed to step 4
  3. Continue to reassess patient-ventilator synchrony and oxygenation
    1. If sustained improvement, repeat IV push dosing q6-8 hours as detailed in specific medications-NMB
    2. If ventilator dys-synchrony recurs. Administer a 2nd IV push dose of paralytic
      1. If sustained improvement, repeat IV dosing q6-8 hours
      2. If transient improvement but then recurrence of vent dys-sycnhrony, then start continuous infusion
    1. If no obvious improvement, re-consider if NMB is beneficial
  4. Administer 2nd IV push dose of paralytic and reassess patient ventilator synchrony and oxygenation
    1. If notable improvement, move to step 3
    2. If no improvement, NMB unlikely to be beneficial
  5. All patients receiving NMB should ophthalmic ointment to keep eyes hydrated

Table of NMB Medications

HOME MEDICATIONS

ACE Inhibitors/ARBs

Summary: The decision to discontinue outpatient ACEi/ARBs should be made based on underlying cardiac comorbidities and the risk/benefit of discontinuation. In critically ill patients at risk for AKI (e.g., shock, multi-organ failure), it is reasonable to discontinue ACEi/ARBs at ICU admission. The associations between ACEi/ARBs and COVID-19 are unclear.

Evidence: There are hypotheses that ACEi/ARBs could improve (Gurwitz) or worsen (Fang et al.) COVID-19 related outcomes. Patients with hypertension and diabetes are at increased risk for COVID-19 (Guan et al.) and COVID-19-related complications (Zhou et al.), but no studies have evaluated the specific association between ACEi/ARBs and COVID-19. The AHA, ACC, and Heart Failure Society of America recommend continuation of ACEi/ARBs in patients with cardiovascular disease but that individualized decisions be made according to each patient’s hemodynamic status and clinical presentation.

NSAIDs

Summary: In most patients, it is reasonable to discontinue NSAIDs at ICU admission given the risk of AKI and bleeding with NSAID use during critical illness. There are anecdotal reports of more severe disease among those taking NSAIDS prior to hospitalization, the significance of which is unclear. Consider substitution with acetaminophen if necessary.

Evidence: The association between NSAIDs and COVID-19 is unclear. On March 14th, 2020, The French health ministry updated guidelines stating that paracetamol should be used for the treatment of COVID-19-related fever and pain and that there have been reports of NSAID-related serious adverse events. WHO does not recommend avoiding NSAIDs for COVID-19 symptoms. In general, NSAIDS should be avoided in critically ill patients given risks of renal failure Hoste et al. and bleeding.

TARGETED TREATMENTS

Remdesivir should be initiated as per BMC protocol here. Corticosteroids should be routinely inintiated as per above section under organ dysfunction. All other anti-viral and immunomodulatory directed therapies are EXPERIMENTAL and based on pre-clinical data, expert opinion, small and emerging clinical studies and consensus statements. The WHO and NIH currently advises against the use of these treatments outside of the clinical trial context. Consider enrollment in clinical trial (several are on-going at BMC).

TRACHEOSTOMY IN COVID-19 ARDS

Recommendation

We do not recommend routine early tracheostomy in COVID-19 patients at this time. We recommend avoiding tracheotomy in COVID-19 positive patients during periods of respiratory instability or heightened ventilator dependence. Tracheotomy can be considered in patients with stable pulmonary status but should not take place sooner than 2-3 weeks from intubation.

Rationale

There is no available data on the role of tracheotomy in patients with COVID-19 respiratory failure. RCTs comparing early vs late tracheotomy in mechanically ventilated patients suggested that early tracheostomy was not associated with a difference in mortality or in the duration of mechanical ventilation. There was a decrease in the number of days requires administration of sedation (Young et al. 2013, Hosokowa et al. 2015). The majority of these patients were in medical ICUs. In a retrospective analysis of patients with ARDS, early tracheotomy was associated with longer duration of mechanical ventilation, ICU stay and potentially prolonging death (Abe et al. 2018).

Selecting Candidates for Tracheostomy

  • Hemodynamically stable off vasopressor support.
  • Stable on volume control or pressure support with PEEP less than or equal to 10 cm H2O and FiO2 less than or equal to 50%
    • In order to ensure that candidates can tolerate the loss of PEEP and de-recruitment associated with the tracheostomy procedure, the candidate should undergo a 60-second apnea trial. A successful apnea trial should result in stable hemodynamics and an oxygen saturation should remain above 80%.
  • Afebrile off of antipyretics for 72 hours
  • Negative nasopharyngeal and tracheal aspirate tests at least 24 hours apart
    • Negative tracheal aspirate test within 48 hours of planned tracheostomy
    • Positive tests that are thought to be clinically irrelevant and negative tests outside the 48 hour window should be discussed between the intensivisit and surgeon

Consultation with General Surgery or ENT and appropriate infection control measures should be abided by.

END OF LIFE CONSIDERATIONS

Important contact information

  • Ethics pager: 4636
  • Legal pager: 1523
  • Patient advocate pager: 7178
  • Palliative care pager: 0179

Current visitor policy

  • Check here for the latest visitor policy. Currently, each patient may designate one visitor who is permitted to visit daily.
  • Care team can make a visitor exception for patients at end of life, but all visitors must be over 18, and will be screened for COVID-19 symptoms. Only one visitor at a time, and each visit is only 15 minutes long.

On arrival for all patients

  • Confirm patient code status, document details in note
  • Priority to establish HCP early, with accurate contact information
  • Designate (with guidance of pt/HCP) one “contact person” for family/friends

Goals of Care in Patients at High Risk of Death

  • CPR may not offer benefit for COVID-19 patients, particularly those with advanced age (>80 years old) and/or comorbid cardiovascular disease, diabetes, hypertension, and respiratory disease.
  • Performing CPR on patients with COVID-19 will increase transmission to healthcare workers, threatening their own well-being and reducing their availability to treat future patients.
  • Attending physicians are not obligated to offer or provide CPR if resuscitative treatment would be medically inappropriate, even at the request of a patient or legally authorized representative.
  • In patients with COVID-19 the risks to healthcare providers of performing CPR may influence a determination that CPR is not medically appropriate, if coupled with considerations of individual patient’s prognosis.
  • Massachusetts DPH crisis standards of care

Palliative Care

With the increase need for palliative care services, we now need to efficiently utilize the BMC palliative care team.

Self-education

Palliative care service

  • When making a palliative care service consult, the palliative care service will work with the primary team to determine the level of care needed by the team, ranging from tips/suggestions to full outreach to patient/family.
  • Please see palliative care resources section on the intranet page covering COVID-19 management (VPN or on-site access required)

PULMONARY DISEASE & COVID-19

Influenza

BMC 2020 Influenza tip sheet

BMC influenza risk and treatment guidelines

CDC guidelines for SARS-COV-2 and influenza

There are few studies regarding outcomes, complications, or efficacy of therapeutics in Influenza and SARS-CoV-2 co-infected patients on which to base recommendations. This is likely due to the very low influenza incidence in the Southern Hemisphere this past season, likely a consequence of distancing measures taken to prevent SARS-CoV-2 infection. Therefore, all recommendations are based on expert opinion.

Prevention

  • CDC Guidance for influenza immunization
  • Unless there is a specific contraindication, all SARS-CoV-2 uninfected patients should be encouraged to receive an influenza vaccination.
  • To limit exposure of healthcare workers and patients to SARS-CoV-2, outpatients with COVID-19, or a close contact of a person with COVID-19, routine clinic visits for vaccination should be deferred until criteria have been met to discontinue isolation.
  • Inpatients diagnosed with COVID-19 should receive influenza vaccination at the discretion of their inpatient team, based on the patient’s current medical condition. Any moderate to severe illness with or without fever is a precaution to vaccination.

Diagnosis

There is no evidence that influenza and SARS-CoV-2 infections are exclusive, therefore patients presenting with compatible constellation of symptoms (URI or ILI) should be tested for both SARS-CoV2, influenza and other respiratory viruses. This is most easily achieved with the comprehensive respiratory panel (which includes SARS-CoV-2), or combination of SARS-CoV2 test and Influenza A/B test.

Treatment

Patients should be started on empiric SARS-CoV-2 and Influenza treatment, based on standard protocols. In instances where one agent has been diagnosed, but there remains high suspicion for co-infection with other agent, empiric treatment for both should be continued while awaiting confirmatory testing, or until therapy has been completed.

Asthma

Association between Asthma and COVID-19

There is limited data at this time regarding whether asthma is a specific risk factor for COVID-19 infection, or if COVID-19 causes increased pathology in asthma patients with COVID-19.

  • The CDC has stated that persons with moderate-to-severe asthma might have an increased risk of severe illness from CODID-19.
  • Evidence thus far from observational studies and studies of asthma registries have not shown an association between asthma and severe COVID-19 disease, nor have studies shown that inhaled corticosteroids are protective or detrimental.

Routine management of Asthma Patients

It is crucial to maintain good asthma control to limit their exposure to COVID-19 in clinical settings

  • Encourage patients to self-isolate and practice social distancing.
  • Maintain all asthma control medications, specifically inhaled corticosteroids and biologic agents, even those requiring in-person nursing visit
  • If a patient using nebulized medications regularly at home, consider doing so away from individuals who may be at higher risk of complications from COVID-19 (i.e., elderly family members)
  • Continue to support the use of asthma controlling medications by facilitating access to the medications in pharmacy, as well as prioritizing administration of biologic agents via clinic visits.
  • Encourage the transition of routine and urgent clinic visits for asthma management to televisits.

Management of asthma exacerbations

Pharmacologic strategy for the treatment for acute asthma exacerbations should not change, regardless of COVID-19 status

  • Promptly utilize systemic corticosteroids (e.g. 0.5-1mg/kg prednisone) for all patients with acute asthma exacerbations. While symptoms of COVID-19 and an asthma exacerbation may be similar, consider treatment for an acute asthma exacerbation if the patient has wheeze, cough, or endorses similar symptoms to previous exacerbations.
  • Continue to administer standing and PRN bronchodilators
    • For hospitalized patients with COVID-19 or PUI, and symptoms of asthma exacerbation, do not administer nebulized medications, administer bronchodilators via metered dose inhaler (MDI). When substituted for a nebulizer treatment, the dose of albuterol MDI is 4 to 8 inhalations, administered as separate inhalations with a valved holding chamber.
    • Consult pharmacy on recommendations for ways to efficiently use MDI and preserve current hospital supplies, e.g., having patients bring in home medications.
  • • Patients with asthma exacerbations who may need more than nasal cannula support should have MICU consultation.

COPD

Association between COPD and COVID-19

  • Pre-existing COPD is associated with increased risk of admission to ICU, mechanical ventilation and death in patients with COVID-19. As with asthma, there is insufficient evidence to determine whether COVID-19 infection increases risk for acute exacerbation of COPD(Guan et al. 2020). While symptoms of COVID-19 and a COPD exacerbation may be similar, consider treatment for an acute COPD exacerbation if the patient has wheeze, cough (per GOLD guidelines), or endorses similar symptoms to previous exacerbations.

Routine management of COPD Patients

It is crucial to maintain good symptom control in COPD patients to limit their exposure to COVID-19 in clinical settings

  • Encourage patients to self-isolate and practice social distancing.
  • Maintain all usual COPD medications, including inhaled corticosteroids, systemic steroids, bronchodilators and supplemental O2.
  • Continue to support the use of COPD controller medications by facilitating access to the medications in pharmacy.
  • If a patient uses nebulized medications regularly at home, consider doing so away from individuals who may be at higher risk of complications from COVID-19 (i.e., elderly family members).
  • Encourage the transition of routine and urgent clinic visits for COPD management to televisits.

Management of COPD exacerbations

Pharmacologic strategy for the treatment for acute COPD exacerbations should not change, regardless of COVID-19 status

  • Promptly utilize systemic corticosteroids (e.g. 0.5-1mg kg prednisone) for all patients with acute COPD exacerbations
  • Continue to administer standing and PRN bronchodilators
    • For patients with COVID-19 and PUI, and symptoms of COPD exacerbation, do not administer nebulized medications, administer via MDI. When substituted for a nebulizer treatment, the dose of albuterol MDI is 4 to 8 inhalations, administered as separate inhalations with a valved holding chamber. The dose of ipratropium MDI is 4 to 8 inhalations, also by valved holding chamber.
    • Consult pharmacy on recommendations for ways to efficiently use MDI and preserve current hospital supplies, e.g., having patients bring in home medications.
  • Patients with COPD exacerbations who may need more than nasal cannula support should have a MICU consultation for NIV.

Pulmonary Hypertension

Association between Pulmonary Hypertension and COVID-19

There is no mention of pulmonary hypertension and COVID-19 in the medical literature

  • Assume patients with pulmonary hypertension are a high-risk population:
    1. Many have co-existent CHF (right or left-sided)
    2. Increased risk for immunosuppression – connective tissue disease, sarcoidosis, sickle cell disease
    3. Often have co-existent lung disease – Group 3 PH

Management of inpatients with pulmonary arterial hypertension (PAH)

  • Continue all PAH specific medications in COVID-19 patients.
    • Currently, the following PAH medications are available on BMC formulary:
      • IV epoprostenol or treprostinil
      • Oral sildenafil, tadalafil and ambrisentan
      • Note Inhaled treprostinil (Tyvaso) is delivered via a device which has some similarities to a nebulizer machine (and some differences). There is concern that use of this device will result in increased aerosolization and because of this, we are recommending stopping this medication on patients admitted with COVID infection or COVID suspects. Patients can be given inhaled NO (even if not intubated) in its place and Respiratory Therapy can be contacted to arrange this.
    • Traditionally, these medications would need to be brought from home for inpatients but if policies do not allow this, the PH consult service will assist with working with BMC pharmacy to acquire them
  • We do not anticipate any medication shortages and each pharmaceutical company in the PAH world has ensured this
  • All specialty pharmacies (Accredo, CVS Caremark, etc) are fully operational and remain the point of contact for medication related issues
  • Sildenafil is under investigation as a potential COVID-19 therapeutic
  • Please consult the PH consult service on all PAH COVID-19 patients in the ICU and/or contact Liz Klings directly with questions.
  • Specialty pharmacy nurse teaching of patients is happening in the hospital remotely

Sickle Cell Disease

Latest guidelines from SCDAA/ASH can be found here

  • Transition outpatient care from in-person to telephonic when at all possible
  • Approximately sixty percent of SCD patients infected with COVID-19 present with increased pain consistent with a vasoocclusive crisis (VOC). Currently all SCD patients presenting with VOC are considered moderate risk for COVID.
  • Monitor for signs of Acute Chest Syndrome (ACS): thrombocytopenia, AKI, hepatic dysfunction, altered mental status, and multi-organ failure. Remember, an infiltrate involving more than 1 segment of the lung + symptoms (fever, cough, chest pain etc) is ACS by definition, regardless of COVID-19 status.
  • Patients with SCD who appear to be at the highest risk for death are those with end organ disease (particularly renal failure and pulmonary hypertension) and those who are older in age (over 50 years old).
  • Hemoglobin genotype does not predict disease severity (HbSC patients are at the same risk for poor outcomes as those with HbSS disease)
  • Contact Liz Klings for guidance for all admitted COVID+ SCD patients. Consult is mandatory on all COVID-19 SCD patients admitted to ICU.
  • Transfusion: We are advocating for early exchange transfusion for SCD COVID+ patients who have pulmonary infiltrates consistent with acute chest syndrome (ACS). For patients with a Hb < 7.0 g/dl can begin with simple transfusion (in light of likely blood shortages) until a Hb of 7 g/dl is achieved. If the patient remains hypoxic with infiltrates with a Hb > 7.0 g/dl, proceed to exchange transfusion.

Lung Cancer and Lung Cancer Screening

Patients eligible for lung cancer screening

Recommendations

  • Consider deferring routine lung cancer screening (initial screening, annual screening, 12 month follow up screening).
  • Patients with an existing abnormal lung cancer screening exam should be triaged based on the exam findings.
    • LungRads 1, 2: Consider delaying annual screening
    • LungRads 3: Consider delaying re-imaging by 3-6 months
    • LungRads 4A, 4B, 4X: Consider referal to Lung Nodule Clinic for telemedicine visit to discuss multi-disciplinary recommendations

Patients with lung nodules

Recommendations

  • Consider delaying re-imaging by 3-6 months for follow up CT imaging for previously detected lung nodules or stable lung nodules for which a CT was originally recommended in 6 or 12 months.
  • Consider delaying re-imaging by 3-6 months for previous CT findings thought to represent inflammatory or infectious processes if the patient is asymptomatic.
  • Consider re-imaging as recommended for patients with prior CT findings concerning for lung malignancy (3 month CT recommended and suspicion for malignancy; PET) provided that hospital capacity permits (see below for patients with suspected lung cancer).

Rationale

Expert guidelines for management of CT Lung Screening or Pulmonary Nodules during the COVID-19 pandemic are now available. These recommendations aim to balance the risk of a patient being harmed by nosocomial infections, including novel coronavirus, and being harmed by late-detection of a potential cancer that might reduce the chance of cure. Most non-small cell lung cancers (NSCLC) have a doubling time of approximately 3-6 months, though a subset may have much faster progression. Cancerous pulmonary nodules grow relatively quickly compared to other types of cancer (e.g. prostate, breast), making management of patients with suspected lung cancer a special consideration. Factors to consider in making decisions regarding lung cancer screening and lung nodule follow-up should include consideration of COVID-19 penetrance, availability of rapid COVID-19 testing, availability of resources, and co-morbid conditions.

Patients with known or suspected lung cancer

Recommendations

  • Conduct proactive and early advance care planning discussions for patients with co-existent cancer and COVID-19. These patients are at higher risk for serious illness (e.g. invasive ventilation, ICU stay) and death. Seek input from palliative care and/or ethics as needed.
  • Consider holding lung cancer chemotherapy or immunotherapy for hospitalized patients with active COVID-19.
  • Multi-disciplinary discussion (e.g. Thoracic Tumor Board) is suggested for all patients with new or suspected lung cancer in order to obtain a consensus recommendation for management that balances the relative benefits and harms of various approaches. Contact Mary Clancy NP () to arrange this. Specific guidance on thoracic surgical recommendations depend on the hospital phase of the pandemic, and include:
    • Phase 1: Few COVID-19 patients, hospital resources not exhausted, institution still has ICU vent capacity, and COVID trajectory not in rapid escalation phase; Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next 3 months
      • Cases that need to be done as soon as feasible (recognizing status of the hospital is likely to progress over next few weeks):
        1. Solid or predominantly solid (>50%) lung cancer or presumed lung cancer >2cm, clinical node negative
        2. Node positive lung cancer
        3. Post induction therapy cancer
        4. Staging to start treatment (mediastinoscopy, diagnostic VATS for pleural dissemination)
        5. Patients enrolled in therapeutic clinical trials
      • Cases that should be deferred
        1. Predominantly ground glass (<50% solid) nodules or cancers
        2. Solid nodule or lung cancer < 2 cm
        3. Indolent histology (e.g. carcinoid, slowly enlarging nodule)
        4. Pulmonary Oligometastases – unless clinically necessary for pressing therapeutic or diagnostic indications (i.e. surgery will impact treatment)
        5. Patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs (i.e. particularly high-risk patients)
    • Phase 2: Many COVID-19 patients, ICU and ventilator capacity limited, OR supplies limited or COVID-19 trajectory within hospital in rapidly escalating phase; Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few days
    • Phase 3: Hospital resources are all routed to COVID-19 patients, no ventilator or ICU capacity, OR supplies exhausted; Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few hours
  • Initiation of chemotherapy or immunotherapy for patients with lung cancer and COVID-19 will be made on a case-by-case basis depending on clinical urgency and treatment options. Consults by medical oncology will continue in a timely manner, with telemedicine consults used where possible/appropriate.
  • Radiation therapy (ongoing or new) for patients with lung cancer and COVID-19 will be made on a case-by-case basis depending on clinical urgency and other treatment options. Consults for radiation therapy will continue in a timely manner, with telemedicine consults used where possible/appropriate.

Rationale

Patients with cancer and COVID-19 are at higher risk for severe events including invasive ventilation, ICU admission, and death (HR 3.56). Recent treatment and age were associated with more severe events. Patients with cancer and COVID-19 also appeared to deteriorate more rapidly. Although there is one case report of a 57 year old man with EGFR-mutant NSCLC on osimertinib admitted with SARS-CoV-2 in whom immunotherapy was continued, we do not routinely recommend this approach given other data suggesting that recent therapy across all cancers was associated with more severe COVID19-related events. Considerations regarding surgical resection, chemotherapy, or radiation of therapy for lung cancers of lung cancers aim to balance the risk of infection, including COVID-19, with the risk of reducing chance of cure, and hospital resources that are available based on the phase of the pandemic. While delaying start dates for chemotherapy and/or radiation therapy has quickly become routine practice nation-wide for certain cancers with good prognosis (e.g. early-stage breast cancer, prostate cancer), given the worse prognosis of lung cancer most should be treated in a timely manner. Again, these decisions will be made on a case-by-case basis after multidisciplinary discussion.

Sarcoidosis

Association between Sarcoidosis and COVID-19

There is no medical literature to guide the management of sarcoidosis patients with COVID-19. Our sarcoidosis is joining a multi-center registry, and we will share any new information/guidance as it becomes available.

Contact pulmonary consult with any additional questions/concerns

Interstial Lung Disease

  • Patients with ILD are at increased risk for complications including a four-fold increase in mortality related to COVID-19
  • There is insufficient evidence to recommend preemptive discontinuation of immunosuppressive therapy and/or antifibrotic medications in ILD patients who have not tested positive or exhibited signs/symptoms of COVID-19. Preemptive discontinuation of therapy may lead to exacerbation of the underlying disease with resultant need for increased healthcare utilization. This approach is supported by statements from American and other dermatology , rheumatology, and gastroenterology societies.
  • Patients receiving immunomodulatory agents with COVID-19 are at increased risk for severe disease, and the decision to discontinue glucocorticoids, biologics, or other immunosuppressive drugs in the setting of infection must be determined on a case-by-case basis. Although it is reasonable to discontinue biologics and/or immunosuppressive drugs until the patient recovers from COVID-19, special caution should be given when considering discontinuation of chronic prednisone as this may lead to adrenal insufficiency.
  • Regarding the use of antifibrotics in idiopathic pulmonary fibrosis (IPF), there is some evidence from observational studies and case reports suggesting that the use of pirfenidone(Furuya et al. 2017, Vianello et al. 2019) or nintedanib (Tomioka et al. 2017, Ito et al. 2019) during an acute exacerbation of IPF (AE-IPF), may improve outcomes. Viral infections have been associated with AE-IPF and it might be difficult to exclude a component of AE-IPF during COVID-19. Therefore, our recommendation is that the decision regarding discontinuation of antifibrotics in ILD patients with COVID-19 should be determined on a case-by-case basis with consideration to continue therapy while closely monitoring LFTs.
  • Consider initiating discussions regarding advance care planning in the outpatient setting or early during admission.

Obstructive Sleep Apnea

Home: Patients who use CPAP or Bilevel PAP or ASV devices

If there is concern that a patient may be infected with COVID-19 coronavirus, continuation of PAP therapy depends on several factors (e.g. apnea severity, high-risk household members, ability to sleep in a separate room). If a patient with COVID-19 continues to use PAP therapy, recommend he/she sleep in a separate room from other household members.

Regional Home Care (RHC) is continuing to set up and troubleshoot mask and machine issues by conducting telemedicine calls and on-site visits in select patients.

Helpful for guidance for home cleaning of devices here and here

The sleep lab is reopen for testing. Covid-19 testing is not required for diagnostic sleep studies. A negative Covid-19 test is required prior to split-night and CPAP titration studies. The sleep lab reviews all sleep study orders and triages need for split-night (based on BMI and risk for severe OSA) and PAP titration studies. For patients requiring split-night and PAP titrations, the sleep lab personnel reaches out to patients, organizes and orders pre-procedural Covid-19 testing, and reviews covid-19 test results. Patients need to be tested 24 hours prior to sleep study.

COMMUNICATION

Communication is crucial to the successful delivery of safe and effective clinical services.

Information management plans should be established for effective and consistent dissemination of information to relevant stakeholders. These should include daily situation reports and regular updates on unit, organizational, regional and state responses.

A variety of information dissemination methods should be considered to account for physical distancing needed for infection control purposes. These may involve video and teleconferencing, and electronic communication platforms.

Effective lines of communication must be established to ensure that stakeholders are apprised of evolving clinical scenarios and changes in clinical practice guidelines and processes. ICU load and capacity must be measured in real-time and communicated to relevant in-hospital administrative and jurisdictional authorities. It is vital to track both patient outcomes and staff well-being. Specific stakeholders and considerations may include:

  • Organizational chains of command
  • State and national health authorities
  • Inter-departmental communications
  • Staff

Appendix

Pharmacotherapy protocol

Approach to QTc prolonging medications

Analgesia, Sedative, and Neuromuscular Blockade Algorithms

ECMO Referral Guidelines for Boston-Based Hospitals

Procedure for test of responsiveness to inhaled vasodilator therapy

PaO2 Trial is conducted as follows:
1. Pre-trial ABG drawn for baseline PaO2
2. Patient placed on 30 PPM NO via nasal cannula or ventilator
3. After 1 hour on inhaled NO, a post-trial ABG is drawn and the resulting PaO2 is compared to the pre-trial PaO2.
4. A significant response is defined as an increase in PaO2 of > 20%
5. If the patient is non-responsive to iNO, they will not receive any further pulmonary vasodilators, to include inhaled epoprostenol.

SaO2 Trial is conducted as follows
1. Titrate Pt’s FiO2 to obtain a SaO2 of 88-92%
2. Patient placed on 30 PPM NO via nasal cannula or ventilator
3. After 1 hour on inhaled NO, a post-trial FiO2 titration is performed
4. A significant response is defined as a SaO2 of 88-92% with at least a 10% absolute reduction in FiO2 (i.e. from 60% to 50%)
5. If the patient is non-responsive to iNO, they will not receive any further pulmonary vasodilators, to include inhaled epoprostenol.