Definition of ARDS

1. New or worsening respiratory symptoms within one week of known clinical insult.
2. Chest imaging (X-ray/CT scan): bilateral opacities, not fully explained by effusions, lobar or lung collapse. Respiratory failure not fully explained by cardiac failure or fluid overload.
1. Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cmH2O, 7 or non-ventilated)
2. Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cmH2O, 7 or non-ventilated)
3. Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, 7 or non-ventilated)
4. When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

Treatment

1. Admit the patient Hospital
2. Chloroquine phosphate 250 mg (150 mg base )300 mg (base) BID or Hydroxy Chloroquine 400 mg OD, Orally for 10-days
   PLUS
3. Oseltamivir 150 mg BID, Orally for 10-Days.
   PLUS
4. Darunavir /Cobicistat) (Rezolsta ®) Darunavir 800 mg/Cobicistat 150 mg OD for 2 weeks
   OR
5. Ritonavir + Lopinavir (Kaletra) 500 mg BID for 2 weeks
   PLUS
6. Azithromycin + IV (as per local guidelines for community acquired Pneumonia)
7. And/Plus Consider ( In very high risk patients)…… See below
8. Convalescent Plasma Infusion (2 units of CP. Each unit of plasma (200 -250 ml) will be given over 2 h with an interval of 1 h between the two units)
   Plus Consider
9. Methylprednisolone 40 mg IV BID for 5 days
   PLUS (may consider in severe cases, ****** under investigations (follow local Guidance)
10. Tocilizumab for patients with evidence of cytokine release syndrome IV, (IV infusion: initial dose of 4–8 mg/kg infused over more than 60 minutes. If initial dose not effective, may administer second dose (in same dosage as initial dose) after 12 hours. No more than 2 doses should be given; maximum single dose is 800 mg and not to be infused in the same line with other medications) *****

Steroid use

1. Intravenous glucocorticoid therapy should not be used as initial therapy
2. Should be considered on a case-by-case, for selected patients with refractory shock (defined as a systolic blood pressure &It;90 mmHg for more than one hour following both adequate fluid resuscitation and vasopressor administration).

Treatment - Respiratory Support

1. Non-invasive respiratory support
1. Low flow Nasal Canula: typically, 1-6 liters/minute
2. High Flow Nasal Cannula:
1. front-line approach to noninvasive support
2. This typically requires less maintenance than invasive mechanical ventilation
3. Keep between 15-30 liters/minute.
3. Noninvasive ventilation (BiPAP)
1. Probably isn't useful for most patients
2. Viral filter should be placed in-line with the exhalation tubing to reduce environmental contamination.
3. BiPAP using a helmet interface may be considered

Intubation Procedure

Invasive Mechanical Support

1. What type of ARDS caused by COVID?
1. COVID doesn't appear to cause substantially reduced lung compliance (which is generally a hallmark finding of ARDS).
2. The predominant problem might be one or more of the following (based on current research)
1. Atelectasis (alveolar collapse)
2. Drowning of the alveoli by fluid
3. If atelectasis, then this will be relatively easy to manage. Any strategy to increase the mean airway pressure will treat atelectasis (e.g. APRV or conventional ARDS net ventilation using a high-PEEP strategy).
4. If drowning of the alveoli: this is usually very difficult to manage.
1. Proning may facilitate drainage of secretions.
2. APRV may also be useful to facilitate airway clearance (rapid dumping breaths create expiratory airflow that can facilitate secretion clearance).
2. Conventional ARDS Net Ventilation
1. Tidal volumes should be targeted to a lung-protective range (6 cc/kg ideal body weight).
2. High PEEPs should be utilized.
3. An ARDSnet “high PEEP” table is shown below (guidance only-tailor according to your need)

Renal Support

1. Renal failure requiring dialysis has been reported in patients admitted to ICU.
2. Rhabdomyolysis may contribute to acute renal failure.
3. Patients who develop renal failure has a poor overall prognosis.

ECMO (Cardio-Pulmonary Support)

1. This decision depends on clinical status, local resources and capabilities, patient age and related comorbidities.
2. If younger patient, and suffering from single-organ failure due to a reversible etiology, so many would be excellent candidates for ECMO.
3. VV ECMO could be used for respiratory failure
4. VA ECMO could be useful in patients with fulminant cardiomyopathy and cardiogenic shock