Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
  • Other Publications
    • www.clevelandclinic.org

User menu

  • Register
  • Log in

Search

  • Advanced search
Cleveland Clinic Journal of Medicine
  • Other Publications
    • www.clevelandclinic.org
  • Register
  • Log in
Cleveland Clinic Journal of Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
COVID-19 Curbside Consults

Respiratory failure in patients infected with SARS-CoV-2

Rishik Vashisht, MD and Abhijit Duggal, MD, MPH, MSc
Cleveland Clinic Journal of Medicine August 2020, DOI: https://doi.org/10.3949/ccjm.87a.ccc025
Rishik Vashisht
Department of Critical Care, Respiratory Institute, Cleveland Clinic
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Abhijit Duggal
Department of Critical Care, Respiratory Institute, Cleveland Clinic
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: [email protected]
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

ABSTRACT

The management of patients with COVID-19-induced acute respiratory distress syndrome focuses on identifying the causes for respiratory failure and on following best practices for supportive care with oxygen supplementation and mechanical ventilation. In this patient population, appropriate measures need to be taken to prevent the spread of the coronavirus. Nearly 90% of COVID-19 patients admitted to the ICU need mechanical ventilation and most of these develop severe ARDS, which causes high morbidity and mortality. These patients need to be managed according to guidelines for the low-tidal-volume lung-protective ventilation. Practitioners also need to evaluate for other potential causes of respiratory failure.

INTRODUCTION

Treatment for coronavirus disease 2019 (COVID-19)-induced acute respiratory distress syndrome (ARDS) must be based on best practices and guidelines, as for ARDS due to other causes. Other possible reasons for respiratory failure need to be considered in the care of these patients. At present, no specific therapies have been proven to be beneficial, and supportive care based on oxygen supplementation and mechanical ventilation, when needed, is the cornerstone of therapy.

A minority of infected patients. In the current global pandemic of severe acute respiratory syndrome coronavirus (SARS-CoV-2), about 5% to 10% of infected patients need to be admitted to the intensive care unit (ICU), most often because of severe and rapidly evolving hypoxemia.1,2 Their most common diagnosis is COVID-19 pneumonia, presenting with fever, fatigue, dry cough, myalgia, and dyspnea. Up to 88% of COVID-19 patients who are admitted to the ICU need mechanical ventilation,2 and most mechanically ventilated patients go on to develop severe ARDS.3

MANAGEMENT OF ACUTE RESPIRATORY FAILURE

Oxygen per high-flow nasal cannula. Patients with COVID-19 pneumonia who have rapidly escalating oxygen requirements should be moved to an ICU and should receive supplemental oxygen through a high-flow nasal cannula to maintain oxygen saturation between 92% and 96%.4

A high-flow nasal cannula is recommended over noninvasive positive-pressure ventilation (NIPPV), which has a very high failure rate in ARDS patients and is associated with poor outcomes. NIPPV may aggravate lung injury in these patients due to large swings in trans-pulmonary pressures and tidal volumes. Also of concern is that NPPV generates aerosols that can spread the virus to other patients and to healthcare providers.4

Low threshold for intubation. In view of the rapidly fulminant progression of this disease, intubation should not be delayed while trying other, unproven therapies. Delay in intubation is associated with worse outcomes in viral pneumonia, so if adequate oxygenation is not achieved with a high-flow nasal cannula, intubation should not be delayed for a trial of NIPPV.

We do not recommend awake prone positioning. Although cases have been reported in which patients avoided intubation by being placed in the prone position, there is insufficient evidence in support its efficacy or safety. Further, trying awake prone positioning may delay necessary intubation and lead to poor outcomes.

MANAGEMENT OF ARDS

Once intubated, patients need to be managed according to the low-tidal-volume lung-protective ventilation strategy tested in the Acute Respiratory Distress Syndrome Network study5 and recommended by the Surviving Sepsis Campaign COVID-19 panel.4

Low tidal volumes: 4 to 8 mL per kg of predicted body weight.4

Plateau pressures: lower than 30 cm H2O.4

High PEEP. COVID-19-associated ARDS responds dramatically to a high positive end-expiratory pressure (PEEP) strategy, with recruitment of the lung parenchyma. A modified high-PEEP strategy (Table 1)6 should be considered. These patients should be placed on high PEEP,4 and the fraction of inspired oxygen (Fio2) should be reduced quickly once they are clinically stable. PEEP down-titration needs to be very slow, as there is a high risk of decruitment in these patients.

View this table:
  • View inline
  • View popup
TABLE 1

A high-PEEP, low Fio2 strategy

Conservative fluid management. Other ARDS trials have clearly demonstrated better outcomes with conservative fluid management.7 Therefore, for patients who are not in shock, a net negative fluid balance using the Fluid and Catheter Treatment Trial Lite protocol8 should be attempted (Table 2).

View this table:
  • View inline
  • View popup
TABLE 2

Simplified conservative fluid management protocol (Fluid and Catheter Treatment Trial Lite)

Consider early prone position ventilation for patients with moderate to severe ARDS (PaO2-FiO2 ratio less than 150, on FiO2 0.6 or greater), in view of the recruitability of the lung parenchyma.4

Consider neuromuscular blocking agents only for ventilator dyssynchrony despite optimal use of sedation. Consider boluses of neuromuscular blocking agents as the initial treatment of choice instead of continuous infusions to help with synchrony.4

We suggest dexamethasone for management of COVID-19 ARDS. This suggestion is based on a preliminary report of a randomized control trial that showed the dexamethasone group had a significantly lower 28-day mortality (21.6% vs 24.6%; P < 0.001), the effect being more pronounced in patients receiving invasive mechanical ventilation (29.0% vs. 40.7%; P < 0.001) and supplemental oxygen (21.5% vs. 25.0%; P = 0.022) (https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1).

Recruitment maneuvers have little or no role, according to current evidence and expert opinion.

Consider extracorporeal membrane oxygenation as a rescue intervention for refractory hypoxemia.4

Start appropriate antibiotics if secondary infection is suspected. Based on early experience, ARDS due to COVID-19 behaves like ARDS due to other viruses, with an average duration of mechanical ventilation of around 2 weeks. This prolonged duration of mechanical ventilation puts patients at risk for developing secondary bacterial pneumonias.

TWO PHASES OF COVID-19 PNEUMONIA?

Gattinoni et al9 hypothesize that COVID-19 pneumonia has two distinct phases of respiratory failure. The initial phase, “type L,” is characterized by low elastance or normal compliance, low ventilation-to-perfusion ratio, low lung weight, and low lung recruit-ability. With continued inflammation, the alveolar capillary membrane permeability increases, leading to increased interstitial edema, increased lung weight, and dependent atelectasis. They describe this phase as “type H,” or typical ARDS. It is characterized by high elastance, high right-to-left shunt, increased lung weight, and high recruitability.

Some suggest treating the early (type L) phase with low PEEP and a less-restrictive tidal volume strategy. However, in the absence of any evidence, we suggest that mechanically ventilated patients should continue to be managed with low-tidal-volume and high-PEEP strategies.

TO AVOID SPREADING THE VIRUS WHEN CARING FOR VENTILATED PATIENTS

Mechanical ventilation and other care for patients with acute respiratory failure is associated with a higher risk of nosocomial transmission. Therefore, caregivers should keep the following in mind.

Minimize unnecessary disconnection of the endotracheal tube to avoid derecruitment and unnecessary release of the virus into the environment.

Adhere to personal protective equipment protocols.

Keep fittings tight. Ventilator circuits need to have tight seals to prevent aerosolization.

Place ventilator and intravenous line monitors outside the room to allow frequent ventilator adjustments while simultaneously decreasing the risk of exposure to staff.

Provide other general supportive care such as sedation, delirium prevention, and infection surveillance based on standard ICU practice and protocols.

CONSIDER OTHER CAUSES OF RESPIRATORY FAILURE

Asthma, COPD exacerbations. Like most other viral infections, COVID-19 pneumonia can lead to exacerbations of both chronic obstructive pulmonary disease (COPD) and asthma.10 SARS-CoV-2 infections can trigger an inflammatory reaction leading to these exacerbations, which need to be managed with corticosteroids and bronchodilators based on best practice guidelines for the underlying disease processes.

Pulmonary embolism. Initial observational data have suggested abnormal coagulation patterns in COVID-19 patents. One study found that up to 31% of patients with COVID-19 infection who required ICU care had thrombotic complications, with pulmonary embolism being the prominent diagnosis.11

We suggest checking D-dimer at admission and every other day.

  • If the initial D-dimer value is less than 3,000 ng/mL we suggest standard thromboprophylaxis.

  • If the initial D-dimer value is higher than 3,000 ng/mL, we suggest point-of-care ultrasonography to assess for thrombotic events. If no thrombosis is detected, consider thromboprophylaxis in a higher dose.

Heart failure. COVID-19 patients who otherwise have minimal lung involvement could potentially present with dyspnea and hypoxemia that may be triggered by pulmonary embolism and right heart failure.

Myocarditis. SARS-CoV-2 infections have also been linked to myocarditis as a result of direct myocardial injury leading to severe heart failure exacerbations and cardiogenic shock. These patients can present with signs and symptoms ranging from mild dyspnea to acute pulmonary edema or even sudden cardiac death. Cardiac involvement can be seen in up to 25% of cases; therefore, we suggest following serial troponin measurements on presentation.

Footnotes

  • The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.

  • Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Wu Z,
    2. McGoogan JM
    . Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; 323(13):1239-1242. doi:10.1001/jama.2020.2648
    OpenUrlCrossRefPubMed
  2. ↵
    1. Grasselli G,
    2. Zangrillo A,
    3. Zanella A, et al
    . Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA April 2020. doi:10.1001/jama.2020.5394
    OpenUrlCrossRefPubMed
  3. ↵
    1. Zhu N,
    2. Zhang D,
    3. Wang W, et al
    . A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; 382(8):727-733. doi:10.1056/NEJMoa2001017
    OpenUrlCrossRefPubMed
  4. ↵
    1. Alhazzani W,
    2. Møller MH,
    3. Arabi YM, et al
    . Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Read Online Crit Care Med | Soc Crit Care Med 9000; Online First. https://journals.lww.com/ccmjournal/Fulltext/onlinefirst/Surviving_Sepsis_Campaign__Guidelines_on_the.95707.aspx.
  5. ↵
    1. Acute Respiratory Distress Syndrome Network,
    2. Brower RG,
    3. Matthay MA,
    4. Morris A,
    5. Schoenfeld D,
    6. Thompson BT,
    7. Wheeler A
    . Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342(18):1301–1308. doi:10.1056/NEJM200005043421801
    OpenUrlCrossRefPubMed
  6. ↵
    1. ARDS Clinical Network
    . Prospective randomized, multi-center trial of higher end-expiratory lung volume/lower FiO2 versus lower end-expieratory lung volume/higher FiO2 ventilation in acute lung injury and acute respiratory distress syndrome. Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury (ALVEOLI) active research protocol. July 20, 1999. http://www.ardsnet.org/files/alveoliV1_1999-07-20.pdf. Accessed April 17, 2020.
  7. ↵
    1. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network,
    2. Wiedemann HP,
    3. Wheeler AP,
    4. Bernard GR, et al
    . Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354(24): 2564–2575. doi:10.1056/NEJMoa062200
    OpenUrlCrossRefPubMed
  8. ↵
    1. Grissom CK,
    2. Hirshberg EL,
    3. Dickerson JB, et al
    . Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome. Crit Care Med 2015;43(2):288-295. doi:10.1097/CCM.0000000000000715
    OpenUrlCrossRef
  9. ↵
    1. Gattinoni L,
    2. Chiumello D,
    3. Caironi P, et al
    . COVID-19 pneumonia: different respiratory treatment for different phenotype? Intensive Care Med 2020. doi:10.1007/s00134-020-06033-2
    OpenUrlCrossRef
  10. ↵
    1. Hewitt R,
    2. Farne H,
    3. Ritchie A,
    4. Luke E,
    5. Johnston SL,
    6. Mallia P
    . The role of viral infections in exacerbations of chronic obstructive pulmonary disease and asthma. Ther Adv Respir Dis 2016; 10(2):158-174. doi:10.1177/1753465815618113
    OpenUrlCrossRefPubMed
  11. ↵
    1. Klok FA,
    2. Kruip MJHA,
    3. Van Der Meer NJM, et al
    . Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020; (xxxx):1-3. doi:10.1016/j.thromres.2020.04.013
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Cleveland Clinic Journal of Medicine: 92 (5)
Cleveland Clinic Journal of Medicine
Vol. 92, Issue 5
1 May 2025
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
  • Complete Issue (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Respiratory failure in patients infected with SARS-CoV-2
(Your Name) has sent you a message from Cleveland Clinic Journal of Medicine
(Your Name) thought you would like to see the Cleveland Clinic Journal of Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Respiratory failure in patients infected with SARS-CoV-2
Rishik Vashisht, Abhijit Duggal
Cleveland Clinic Journal of Medicine Aug 2020, DOI: 10.3949/ccjm.87a.ccc025

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Respiratory failure in patients infected with SARS-CoV-2
Rishik Vashisht, Abhijit Duggal
Cleveland Clinic Journal of Medicine Aug 2020, DOI: 10.3949/ccjm.87a.ccc025
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Linkedin Share Button

Jump to section

  • Article
    • ABSTRACT
    • INTRODUCTION
    • MANAGEMENT OF ACUTE RESPIRATORY FAILURE
    • MANAGEMENT OF ARDS
    • TWO PHASES OF COVID-19 PNEUMONIA?
    • TO AVOID SPREADING THE VIRUS WHEN CARING FOR VENTILATED PATIENTS
    • CONSIDER OTHER CAUSES OF RESPIRATORY FAILURE
    • Footnotes
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Update to COVID-19 serologic testing : FAQs and caveats
  • Update to post-acute sequelae of SARS-CoV-2 infection: Caring for the 'long-haulers'
  • COVID-19 in older adults
Show more COVID-19 Curbside Consults

Similar Articles

Navigate

  • Current Issue
  • Past Issues
  • Supplements
  • Article Type
  • Specialty
  • CME/MOC Articles
  • CME/MOC Calendar
  • Media Kit

Authors & Reviewers

  • Manuscript Submission
  • Authors & Reviewers
  • Subscriptions
  • About CCJM
  • Contact Us
  • Cleveland Clinic Center for Continuing Education
  • Consult QD

Share your suggestions!

Copyright © 2025 The Cleveland Clinic Foundation. All rights reserved. The information provided is for educational purposes only. Use of this website is subject to the website terms of use and privacy policy. 

Powered by HighWire