Critical care management of adults with community-acquired severe respiratory viral infection

Abstract

With the expanding use of molecular assays, viral pathogens are increasingly recognized among critically ill adult patients with community-acquired severe respiratory illness; studies have detected respiratory viral infections (RVIs) in 17-53% of such patients. In addition, novel pathogens including zoonotic coronaviruses like the agents causing Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS) and the 2019 novel coronavirus (2019 nCoV) are still being identified. Patients with severe RVIs requiring ICU care present typically with hypoxemic respiratory failure. Oseltamivir is the most widely used neuraminidase inhibitor for treatment of influenza; data suggest that early use is associated with reduced mortality in critically ill patients with influenza. At present, there are no antiviral therapies of proven efficacy for other severe RVIs. Several adjunctive pharmacologic interventions have been studied for their immunomodulatory effects, including macrolides, corticosteroids, cyclooxygenase-2 inhibitors, sirolimus, statins, anti-influenza immune plasma, and vitamin C, but none is recommended at present in severe RVIs. Evidence-based supportive care is the mainstay for management of severe respiratory viral infection. Non-invasive ventilation in patients with severe RVI causing acute hypoxemic respiratory failure and pneumonia is associated with a high likelihood of transition to invasive ventilation. Limited existing knowledge highlights the need for data regarding supportive care and adjunctive pharmacologic therapy that is specific for critically ill patients with severe RVI. There is a need for more pragmatic and efficient designs to test different therapeutics both individually and in combination.

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

“…Multi disciplinary team involvement with an infectious disease specialist should be seen as a minimum requirement to further patient management, given the need for subspecialty knowledge regarding testing, monitoring, therapeutics, and containment. 26 We recommend that ECMO centres formulate a minimum and an ideal staffing requirement and communicate them to the local, regional, and national networks to facilitate staffing allocation in case ECMO team members become ill or otherwise unavailable.…”

Coronavirus Disease 2019 (COVID-19): A critical care perspective beyond China

“…During aerosol-generation procedures, wearing a fit-tested N95 mask in addition to gloves, gown and face/eye protection is recommended. Open suctioning of the respiratory tract, manual ventilation before intubation, nebuliser treatment, and chest compressions were identified as risk procedures during the SARS outbreak [10]. Close-circuit suctioning may reduce exposure to aerosols in intubated patients.…”

Preparing for COVID-19: early experience from an intensive care unit in Singapore

“…Fourth, we had to reexamine specific ICU services. Given that extracorporeal membrane oxygenation (ECMO) for severe viral pneumonia is well-established [5], we prepared to cohort all COVID-19 patients in the medical ICU and have a satellite team from the cardiothoracic ICU manage the ECMO circuit. Lastly, we realized staff morale took an early hit due to multiple factors, including increased workload due to implementation of strict infection control measures, uncertainty over the effectiveness of personal protective equipment, anxiety over the lethality of any infection, concern for the well-being of their family members and stigmatization by members of the public.…”