COVID-19-associated acute respiratory distress syndrome: Difference between revisions

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{{CMG}}
{{COVID-19}}
 
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''
 
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''
 
{{CMG}}; {{AE}} {{AyeshaFJ}}
 
==Overview==
==Overview==
ARDS has been distributed over different phenotypes over the last decade. The management of COVID-19 related ARDS has been therefore led to different proposal for the management strategies that are stratified according to the type of phenotype. ARDS developed in 20 percent a median of eight days after the onset of symptoms; mechanical ventilation was implemented in 12.3 percent. <ref name="Wang Hu Hu Zhu p=1061">{{cite journal | last=Wang | first=Dawei | last2=Hu | first2=Bo | last3=Hu | first3=Chang | last4=Zhu | first4=Fangfang | last5=Liu | first5=Xing | last6=Zhang | first6=Jing | last7=Wang | first7=Binbin | last8=Xiang | first8=Hui | last9=Cheng | first9=Zhenshun | last10=Xiong | first10=Yong | last11=Zhao | first11=Yan | last12=Li | first12=Yirong | last13=Wang | first13=Xinghuan | last14=Peng | first14=Zhiyong | title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China | journal=JAMA | publisher=American Medical Association (AMA) | volume=323 | issue=11 | date=2020-03-17 | issn=0098-7484 | pmid=32031570 | pmc=7042881 | doi=10.1001/jama.2020.1585 | page=1061}}</ref> The mortality rate of COVID-19 related ARDS is higher in elderly patients. Given the importance of heterogeneity of ARDS profile , appropriate intervention at appropriate time is needed to help preventing the deterioration of lung function. Recent advances in RECOVERY trial has further strengthened this notion that the use of dexamethasone in patients on ventilator can reduce the mortality rate of patients by 1/3rd. The treatment of COVID-19 related ARDS is evolving with time and different treatment options are now available for the better management of ARDS.
==Historical Perspective==
==Historical Perspective==


*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
* The [[novel]] [[coronavirus]] was named as the [[severe acute respiratory syndrome coronavirus-2]] ([[SARS-CoV-2]]) due to its high similarity to [[SARS-CoV]], which caused [[acute respiratory distress syndrome]] ([[ARDS]]) in 2002–2003.
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
* [[SARS-CoV-2]] virus primarily affects the [[respiratory]] [[system]] causing a wide variety of [[respiratory]] [[symptoms]] which can range from [[symptoms]] of [[lower respiratory tract infection]] to severe [[hypoxia]] to [[acute respiratory distress syndrome]] within a very short span of time.
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
* The [[acute respiratory distress syndrome]] ([[ARDS]]) is a common cause of [[morbidity]] and [[mortality]] in critically ill [[COVID-19]] [[infected]] [[patients]]. It is defined by the [[acute]] [[onset]] of [[noncardiogenic]] [[pulmonary]] [[edema]], [[hypoxaemia]] and the need for [[mechanical ventilation]]
 


==Classification==
==Classification==
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==Pathophysiology==
==Pathophysiology==


*The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
* [[ARDS]] arises as a [[complication]] of [[COVID-19]] [[infection]] due to [[acute]] [[inflammation]] of the [[alveolar space]] which prevents normal [[gas exchange]]. The increase in [[proinflammatory]] [[cytokines]] within the [[lung]] leads to recruitment of [[leukocytes]], further propagating the local [[inflammatory response]].<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246  }} </ref>
*The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
* The [[cytokine]] storm and the deadly uncontrolled [[systemic]] [[inflammatory]] response resulting from the release of large amounts of [[proinflammatory]] [[cytokines]] including [[interferons]] and [[interleukins]] and, [[chemokines]] by [[immune]] [[effector cells]] resulting in [[acute]] [[inflammation]] within the [[alveolar space]]. The [[exudate]] containing [[plasma proteins]], including [[albumin]], [[fibrinogen]], [[proinflammatory]] [[cytokines]] and [[coagulation factors]] will increase [[alveolar]]-[[capillary]] [[permeability]] and decrease the normal [[gas exchange]] and [[plasma proteins]], including [[albumin]], [[fibrinogen]], proinflammatory cytokines and coagulation factors.<ref name="pmidPMID: 19801579">{{cite journal| author=Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE| title=Activation and regulation of systemic inflammation in ARDS: rationale for prolonged glucocorticoid therapy. | journal=Chest | year= 2009 | volume= 136 | issue= 6 | pages= 1631-1643 | pmid=PMID: 19801579 | doi=10.1378/chest.08-2408 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19801579  }} </ref>
*On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
*The [[COVID-19]] [[patients]] with [[ARDS]]  show elevated levels of [[IL-6]], [[IFN-a]], and [[CCL5]], [[CXCL8]], [[CXCL-10]] in [[serum]] as compared to those with the mild to moderate [[disease]].<ref name="pmidPMID: 32304191">{{cite journal| author=Tezer H, Bedir Demirdağ T| title=Novel coronavirus disease (COVID-19) in children | journal=Turk J Med Sci | year= 2020 | volume= 50 | issue= SI-1 | pages= 592-603 | pmid=PMID: 32304191 | doi=10.3906/sag-2004-174 | pmc=7195991 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32304191  }} </ref>
*On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
* This [[inflammatory]] [[process]] leads to the [[fibrin]] deposition in the [[air spaces]] and [[lung]] parenchyma and contributes to [[hyaline-membrane]] formation and subsequent [[alveolar]] [[fibrosis]].<ref name="pmidPMID: 2314423">{{cite journal| author=Bertozzi P, Astedt B, Zenzius L, Lynch K, LeMaire F, Zapol W | display-authors=etal| title=Depressed bronchoalveolar urokinase activity in patients with adult respiratory distress syndrome. | journal=N Engl J Med | year= 1990 | volume= 322 | issue= 13 | pages= 890-7 | pmid=PMID: 2314423 | doi=10.1056/NEJM199003293221304 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2314423  }} </ref>
* [[Patients]] [[infected]] with [[COVID‐19]] also exhibit [[coagulation]] [[abnormalities]].This [[procoagulant]] pattern can lead to [[acute respiratory distress syndrome]].<ref name="pmidPMID: 32302448">{{cite journal| author=Ranucci M, Ballotta A, Di Dedda U, Bayshnikova E, Dei Poli M, Resta M | display-authors=etal| title=The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome. | journal=J Thromb Haemost | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32302448 | doi=10.1111/jth.14854 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32302448  }} </ref>
 


==Clinical Features==
==Clinical Features==
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==Epidemiology and Demographics==
==Epidemiology and Demographics==


*The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* [[Incidence]] is higher in the elderly and much lower in children
*In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
* Higher [[mortality rate]] is seen in the elderly.
*A systematic review showed that ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies).


===Age===
===Age===
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===Symptoms===
===Symptoms===


*[Disease name] is usually asymptomatic.
:*[[Dyspnea]]: The onset of [[dyspnea]] is relatively late around the 6th day.<ref name="pmidPMID: 32105632">{{cite journal| author=Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H | display-authors=etal| title=Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 5 | pages= 475-481 | pmid=PMID: 32105632 | doi=10.1016/S2213-2600(20)30079-5 | pmc=7102538 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32105632  }} </ref> <ref name="pmidPMID 32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID 32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570  }} </ref>
*Symptoms of [disease name] may include the following:
:*[[Acute]] [[Hypoxemia]] due to [[respiratory failure]] is a dominant finding.<ref name="pmidPMID: 32228035">{{cite journal| author=Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D| title=COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. | journal=Am J Respir Crit Care Med | year= 2020 | volume= 201 | issue= 10 | pages= 1299-1300 | pmid=PMID: 32228035 | doi=10.1164/rccm.202003-0817LE | pmc=7233352 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32228035  }} </ref>
:*[[Hypercapnia]] could be present but it is [[rare]].<ref name="pmidPMID: 28740647">{{cite journal| author=Repessé X, Vieillard-Baron A| title=Hypercapnia during acute respiratory distress syndrome: the tree that hides the forest! | journal=J Thorac Dis | year= 2017 | volume= 9 | issue= 6 | pages= 1420-1425 | pmid=PMID: 28740647 | doi=10.21037/jtd.2017.05.69 | pmc=5506150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28740647  }} </ref>


:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]


===Physical Examination===
===Physical Examination===
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===Laboratory Findings===
===Laboratory Findings===


*There are no specific laboratory findings associated with [disease name].
* [[Incidence]] is higher in the elderly and much lower in children
 
* Higher [[mortality rate]] is seen in the elderly.
*A  [positive/negative] [test name] is diagnostic of [disease name].
*A systematic review showed that ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies).
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].


===Imaging Findings===
===Imaging Findings===


*There are no [imaging study] findings associated with [disease name].
* [[Chest]] [[CT scan]] shows characteristic ground-glass opacities (GCO). This indicates the presence of [[exudate]] in the [[bronchoalveolar]] [[airspace]].<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246  }} </ref>
 
* [[Lung]] biopsy shows [[fibrin]] deposition.<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246  }} </ref> <ref name="pmidPMID: 32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=PMID: 32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570  }} </ref>
*[Imaging study 1] is the imaging modality of choice for [disease name].
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
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===Medical Therapy===
===Medical Therapy===


*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
==== Fluid and electrolytes management ====
* Studies have shown that in [[ARDS]], [[conservative]] [[fluid management]] may help [[patients]] by reducing [[oedema]] formation. <ref name="pmidPMID 16714767">{{cite journal| author=National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D | display-authors=etal| title=Comparison of two fluid-management strategies in acute lung injury. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 24 | pages= 2564-75 | pmid=PMID 16714767 | doi=10.1056/NEJMoa062200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16714767  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=17080981 Review in: ACP J Club. 2006 Nov-Dec;145(3):69] </ref> <ref name="pmidPMID 25599463">{{cite journal| author=Grissom CK, Hirshberg EL, Dickerson JB, Brown SM, Lanspa MJ, Liu KD | display-authors=etal| title=Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*. | journal=Crit Care Med | year= 2015 | volume= 43 | issue= 2 | pages= 288-95 | pmid=PMID 25599463 | doi=10.1097/CCM.0000000000000715 | pmc=4675623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25599463  }} </ref>
* Conservative [[fluid]] [[management]] with [[buffered]] or [[non-buffered]] [[crystalloid]] is recommended for [[ARDS]] [[patients]].
* The [[conservative]] [[fluid]] strategy results in an increased number of [[ventilator]]-free days and a decreased length of [[ICU]] stay. However, its effect on [[mortality]] remains uncertain. <ref name="pmidPMID 27734109">{{cite journal| author=Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC | display-authors=etal| title=Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. | journal=Intensive Care Med | year= 2017 | volume= 43 | issue= 2 | pages= 155-170 | pmid=PMID 27734109 | doi=10.1007/s00134-016-4573-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27734109  }} </ref>
 
==== Corticosteroids ====
* Recent [[studies]] have shown that the [[corticosteroid]] [[dexamethasone]] may reduce [[mortality]] of severe [[COVID-19]] [[patients]].<ref name="pmidPMID: 32551464">{{cite journal| author=Theoharides TC, Conti P| title=Dexamethasone for COVID-19? Not so fast. | journal=J Biol Regul Homeost Agents | year= 2020 | volume= 34 | issue= 3 | pages=  | pmid=PMID: 32551464 | doi=10.23812/20-EDITORIAL_1-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32551464  }} </ref>
*In England, a non-peer-reviewed [[randomized]] [[trial]] was issued as a press release which suggested that [[dexamethasone]] has a potential survival benefit in [[hospitalized]] [[COVID-19]] [[patients]] requiring [[oxygen]].<ref>{{cite web |url=https://www.gov.uk/government/news/world-first-coronavirus-treatment-approved-for-nhs-use-by-government |title=World first coronavirus treatment approved for NHS use by government - GOV.UK |format= |work= |accessdate=}}</ref>
* The Society of Critical Care Medicine (SCCM) provided a weak conditional [[recommendation]] in the favor of [[glucocorticoids]] in [[patients]] with [[COVID-19]] who have severe [[ARDS]] with a [[partial]] [[arterial pressure]] of [[oxygen]]/[[fraction]] of [[inspired]] [[oxygen]] [[PaO2]]:[[FiO2]]] <100 mmHg). This recommendation suggests benefit in [[patients]] with moderate to severe [[ARDS]] which is [[refractory]] to low [[tidal volume]] [[ventilation]].<ref name="pmidPMID 28940011">{{cite journal| author=Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A | display-authors=etal| title=Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. | journal=Intensive Care Med | year= 2017 | volume= 43 | issue= 12 | pages= 1751-1763 | pmid=PMID 28940011 | doi=10.1007/s00134-017-4919-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28940011  }} </ref>
 
====Mechanical Ventilation====
* [[Mechanical ventilation]] along with [[supportive]] [[therapies]] are the mainstay of [[treatment]] of [[ARDS]].<ref name="pmidPMID: 23825769">{{cite journal| author=Fanelli V, Vlachou A, Ghannadian S, Simonetti U, Slutsky AS, Zhang H| title=Acute respiratory distress syndrome: new definition, current and future therapeutic options. | journal=J Thorac Dis | year= 2013 | volume= 5 | issue= 3 | pages= 326-34 | pmid=PMID: 23825769 | doi=10.3978/j.issn.2072-1439.2013.04.05 | pmc=3698298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23825769  }} </ref>
* [[Invasive]] [[mechanical ventilation]] (ie, [[ventilation]] via an [[endotracheal tube]] or [[tracheostomy]] with [[breaths]] delivered by a [[mechanical ventilator]]) is preferred for [[patients]] with [[ARDS]], particularly those with [[moderate]] or [[severe]] [[ARDS]] (ie, [[arterial]] [[oxygen]] [[tension]]/[[fraction]] of [[inspired]] [[oxygen]] [[PaO2]]/[[FiO2]] ≤200 mmHg on [[positive end-expiratory pressure]] ([[PEEP]]) ≥5 cm [[H2O]]).<ref>{{cite web |url=https://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf?ua=1 |title=www.who.int |format= |work= |accessdate=}}</ref>
* It is recommended to use [[low]] [[tidal volume]] [[ventilation]] ([[LTVV]]) with 4 to 8 mL/kg predicted body weight [PBW]. Several meta-analyses and randomized trials that report a mortality benefit from LTVV in patients with ARDS.<ref name="pmidPMID: 27035237">{{cite journal| author=Weiss CH, Baker DW, Weiner S, Bechel M, Ragland M, Rademaker A | display-authors=etal| title=Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 8 | pages= 1515-22 | pmid=PMID: 27035237 | doi=10.1097/CCM.0000000000001710 | pmc=4949102 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27035237  }} </ref>
* The aim is to maintain [[oxygen]] [[saturation]] between 90% to 96%. The [[severe]] [[hypoxemia]] of the [[COVID-19]] [[ARDS]] best responds when [[Positive end-expiratory pressure]] ([[PEEP]]) is high with [[Pplat]] ≤30 cm H2O. It is beneficial if the [[physician]] starts with higher than usual levels of [[PEEP]] (10 to 15 cm H2O).<ref>{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
*
 
==== Anticoagulant or thrombolytic therapy ====
* [[Fibrinolytic drugs]] such as [[tissue-type plasminogen activator]] ([[tPA]]) degrade pre-existing [[fibrin]] in the [[lungs]].<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213  }} </ref>
* [[Nebulizer]] [[plasminogen activators]] may provide more targeted therapy to degrade [[fibrin]] and improving [[oxygenatio]]n in critically ill patients. It is in Phase II of the [[clinical trial]].
 
==Prevention==
* The [[ARDS]] [[patients]] have an increased [[risk]] of [[hospital]]-associated [[venous thromboembolism]] ([[VTE]]).<ref>{{cite web |url=https://b-s-h.org.uk/media/18171/th-and-covid-25-march-2020-final.pdf |title=b-s-h.org.uk |format= |work= |accessdate=}}</ref>
* Due to this reason, it is advised to take [[low molecular weight heparin]] ([[LMWH]]) [[prophylactically]] in [[patients]] who do not have the contraindications. Studies have shown that the [[heparin]], either unfractionated or [[LMWH]], can also reduce [[inflammatory]] [[biomarkers]] hence could help in reducing the [[inflammation]].<ref name="pmidPMID: 32338827">{{cite journal| author=Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M | display-authors=etal| title=ISTH interim guidance on recognition and management of coagulopathy in COVID-19. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 5 | pages= 1023-1026 | pmid=PMID: 32338827 | doi=10.1111/jth.14810 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32338827  }} </ref>


*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].


===Surgery===
===Surgery===

Revision as of 09:14, 13 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha Javid, MBBS[2]

Overview

ARDS has been distributed over different phenotypes over the last decade. The management of COVID-19 related ARDS has been therefore led to different proposal for the management strategies that are stratified according to the type of phenotype. ARDS developed in 20 percent a median of eight days after the onset of symptoms; mechanical ventilation was implemented in 12.3 percent. [1] The mortality rate of COVID-19 related ARDS is higher in elderly patients. Given the importance of heterogeneity of ARDS profile , appropriate intervention at appropriate time is needed to help preventing the deterioration of lung function. Recent advances in RECOVERY trial has further strengthened this notion that the use of dexamethasone in patients on ventilator can reduce the mortality rate of patients by 1/3rd. The treatment of COVID-19 related ARDS is evolving with time and different treatment options are now available for the better management of ARDS.

Historical Perspective


Classification

  • [Disease name] may be classified according to [classification method] into [number] subtypes/groups:
  • [group1]
  • [group2]
  • [group3]
  • Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].

Pathophysiology


Clinical Features

Differentiating [disease name] from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
  • [Differential dx1]
  • [Differential dx2]
  • [Differential dx3]

Epidemiology and Demographics

  • Incidence is higher in the elderly and much lower in children
  • Higher mortality rate is seen in the elderly.
  • A systematic review showed that ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies).

Age

  • Patients of all age groups may develop [disease name].
  • [Disease name] is more commonly observed among patients aged [age range] years old.
  • [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

  • [Disease name] affects men and women equally.
  • [Gender 1] are more commonly affected with [disease name] than [gender 2].
  • The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

  • There is no racial predilection for [disease name].
  • [Disease name] usually affects individuals of the [race 1] race.
  • [Race 2] individuals are less likely to develop [disease name].

Risk Factors

  • Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

  • The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
  • [criterion 1]
  • [criterion 2]
  • [criterion 3]
  • [criterion 4]

Symptoms


Physical Examination

  • Patients with [disease name] usually appear [general appearance].
  • Physical examination may be remarkable for:
  • [finding 1]
  • [finding 2]
  • [finding 3]
  • [finding 4]
  • [finding 5]
  • [finding 6]

Laboratory Findings

  • Incidence is higher in the elderly and much lower in children
  • Higher mortality rate is seen in the elderly.
  • A systematic review showed that ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies).

Imaging Findings

Other Diagnostic Studies

  • [Disease name] may also be diagnosed using [diagnostic study name].
  • Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

Fluid and electrolytes management

Corticosteroids

Mechanical Ventilation

Anticoagulant or thrombolytic therapy

Prevention


Surgery

  • Surgery is the mainstay of therapy for [disease name].
  • [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • There are no primary preventive measures available for [disease name].
  • Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
  • Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

References

  1. ↑ Wang, Dawei; Hu, Bo; Hu, Chang; Zhu, Fangfang; Liu, Xing; Zhang, Jing; Wang, Binbin; Xiang, Hui; Cheng, Zhenshun; Xiong, Yong; Zhao, Yan; Li, Yirong; Wang, Xinghuan; Peng, Zhiyong (2020-03-17). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China". JAMA. American Medical Association (AMA). 323 (11): 1061. doi:10.1001/jama.2020.1585. ISSN 0098-7484. PMC 7042881 Check |pmc= value (help). PMID 32031570 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ (2020). "Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19". J Thromb Haemost. doi:10.1111/jth.14872. PMC 7264738 Check |pmc= value (help). PMID 32329246 PMID: 32329246 Check |pmid= value (help).
  3. ↑ Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE (2009). "Activation and regulation of systemic inflammation in ARDS: rationale for prolonged glucocorticoid therapy". Chest. 136 (6): 1631–1643. doi:10.1378/chest.08-2408. PMID 19801579 PMID: 19801579 Check |pmid= value (help).
  4. ↑ Tezer H, Bedir Demirdağ T (2020). "Novel coronavirus disease (COVID-19) in children". Turk J Med Sci. 50 (SI-1): 592–603. doi:10.3906/sag-2004-174. PMC 7195991 Check |pmc= value (help). PMID 32304191 PMID: 32304191 Check |pmid= value (help).
  5. ↑ Bertozzi P, Astedt B, Zenzius L, Lynch K, LeMaire F, Zapol W; et al. (1990). "Depressed bronchoalveolar urokinase activity in patients with adult respiratory distress syndrome". N Engl J Med. 322 (13): 890–7. doi:10.1056/NEJM199003293221304. PMID 2314423 PMID: 2314423 Check |pmid= value (help).
  6. ↑ Ranucci M, Ballotta A, Di Dedda U, Bayshnikova E, Dei Poli M, Resta M; et al. (2020). "The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome". J Thromb Haemost. doi:10.1111/jth.14854. PMID 32302448 PMID: 32302448 Check |pmid= value (help).
  7. ↑ Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H; et al. (2020). "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study". Lancet Respir Med. 8 (5): 475–481. doi:10.1016/S2213-2600(20)30079-5. PMC 7102538 Check |pmc= value (help). PMID 32105632 PMID: 32105632 Check |pmid= value (help).
  8. ↑ Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J; et al. (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". JAMA. doi:10.1001/jama.2020.1585. PMC 7042881 Check |pmc= value (help). PMID 32031570 PMID 32031570 Check |pmid= value (help).
  9. ↑ Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D (2020). "COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome". Am J Respir Crit Care Med. 201 (10): 1299–1300. doi:10.1164/rccm.202003-0817LE. PMC 7233352 Check |pmc= value (help). PMID 32228035 PMID: 32228035 Check |pmid= value (help).
  10. ↑ Repessé X, Vieillard-Baron A (2017). "Hypercapnia during acute respiratory distress syndrome: the tree that hides the forest!". J Thorac Dis. 9 (6): 1420–1425. doi:10.21037/jtd.2017.05.69. PMC 5506150. PMID 28740647 PMID: 28740647 Check |pmid= value (help).
  11. ↑ Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J; et al. (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". JAMA. doi:10.1001/jama.2020.1585. PMC 7042881 Check |pmc= value (help). PMID 32031570 PMID: 32031570 Check |pmid= value (help).
  12. ↑ National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D; et al. (2006). "Comparison of two fluid-management strategies in acute lung injury". N Engl J Med. 354 (24): 2564–75. doi:10.1056/NEJMoa062200. PMID 16714767 PMID 16714767 Check |pmid= value (help). Review in: ACP J Club. 2006 Nov-Dec;145(3):69
  13. ↑ Grissom CK, Hirshberg EL, Dickerson JB, Brown SM, Lanspa MJ, Liu KD; et al. (2015). "Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*". Crit Care Med. 43 (2): 288–95. doi:10.1097/CCM.0000000000000715. PMC 4675623. PMID 25599463 PMID 25599463 Check |pmid= value (help).
  14. ↑ Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC; et al. (2017). "Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis". Intensive Care Med. 43 (2): 155–170. doi:10.1007/s00134-016-4573-3. PMID 27734109 PMID 27734109 Check |pmid= value (help).
  15. ↑ Theoharides TC, Conti P (2020). "Dexamethasone for COVID-19? Not so fast". J Biol Regul Homeost Agents. 34 (3). doi:10.23812/20-EDITORIAL_1-5. PMID 32551464 PMID: 32551464 Check |pmid= value (help).
  16. ↑ "World first coronavirus treatment approved for NHS use by government - GOV.UK".
  17. ↑ Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A; et al. (2017). "Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017". Intensive Care Med. 43 (12): 1751–1763. doi:10.1007/s00134-017-4919-5. PMID 28940011 PMID 28940011 Check |pmid= value (help).
  18. ↑ Fanelli V, Vlachou A, Ghannadian S, Simonetti U, Slutsky AS, Zhang H (2013). "Acute respiratory distress syndrome: new definition, current and future therapeutic options". J Thorac Dis. 5 (3): 326–34. doi:10.3978/j.issn.2072-1439.2013.04.05. PMC 3698298. PMID 23825769 PMID: 23825769 Check |pmid= value (help).
  19. ↑ "www.who.int" (PDF).
  20. ↑ Weiss CH, Baker DW, Weiner S, Bechel M, Ragland M, Rademaker A; et al. (2016). "Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome". Crit Care Med. 44 (8): 1515–22. doi:10.1097/CCM.0000000000001710. PMC 4949102. PMID 27035237 PMID: 27035237 Check |pmid= value (help).
  21. ↑ "www.who.int" (PDF).
  22. ↑ Tang N, Li D, Wang X, Sun Z (2020). "Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia". J Thromb Haemost. 18 (4): 844–847. doi:10.1111/jth.14768. PMC 7166509 Check |pmc= value (help). PMID 32073213 PMID: 32073213 Check |pmid= value (help).
  23. ↑ "b-s-h.org.uk" (PDF).
  24. ↑ Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M; et al. (2020). "ISTH interim guidance on recognition and management of coagulopathy in COVID-19". J Thromb Haemost. 18 (5): 1023–1026. doi:10.1111/jth.14810. PMID 32338827 PMID: 32338827 Check |pmid= value (help).

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