Clinical Review & Education

JAMA Insights | CLINICAL UPDATE

Care for Critically Ill Patients With COVID-19

Srinivas Murthy, MD, CM, MHSc; Charles D. Gomersall, MBBS; Robert A. Fowler, MD, CM, MSc

Initial reports suggest that COVID-19 is associated with severe disease

Figure. Summary of Caring for Critically Ill Patients With COVID-19
that requires intensive care in approximately 5% of proven infections.1
Given how common the disease is becoming, as in prior major severe Caring for critically ill patients with COVID-19 is based on the
usual management of viral pneumonia with respiratory failure with additional
acute respiratory infection outbreaks—SARS (severe acute respiratory
precautions to reduce risk of transmission.
syndrome), MERS (Middle East respiratory syndrome), avian influenza
A(H7N9), and influenza A(H1N1)pdm09—critical care will be an inte- Usual critical care
gral component of the global response to this emerging infection. Many patients with severe COVID-19 develop acute respiratory distress
The rapid increase in the number of cases of COVID-19 in Wuhan, syndrome (ARDS). Evidence-based guidelines for ARDS in the context
of COVID-19 include treatments such as
China, in late 2019 highlighted how quickly health systems can be chal- • Conservative intravenous • Lung-protective ventilation strategies
lengedtoprovideadequatecare.1 Case-fatalityproportionswere7-fold fluid strategies • Periodic prone positioning during
• Empirical early antibiotics mechanical ventilation
higher for patients in Hubei Province compared with those outside of
for possible bacterial pneumonia • Consideration of extracorporeal
the region, 2.9% vs 0.4%, emphasizing the importance of health sys- • Consideration for early membrane oxygenation
tem capacity in the care of patients who are critically ill with COVID-19.1 invasive ventilation

Thisarticlediscussesissuespertainingtoregionswherecriticalcare
unitshavethecapacitytoprovidemechanicalventilation,acknowledg- Modifications to usual critical care
ing that this capacity does not exist in many regions and that capacity • Admission of patients with suspected disease to private rooms when possible
could be exceeded in many places. This differential ability to manage • Use of medical face masks for symptomatic patients during assessment
and transfer
the disease will likely have a substantial influence on patient outcomes. • Maintain distancing of at least 2 m between patients
• Caution when using high-flow nasal oxygen or noninvasive ventilation
Factors Associated With Requiring Intensive Care due to risk of dispersion of aerosolized virus in the health care environment
with poorly fitting masks
Appreciatingtypicalclinicalfeaturesanddiseasecoursearecrucialboth
• Clinicians involved with aerosol-generating procedures should use additional
to prepare for increasing numbers of patients and to determine how airborne precautions including N95 respirators and eye protection
to best treat infected persons. Patients who have required critical care
have tended to be older (median age ≈60 years), and 40% have had Facility planning
comorbidconditions,commonlydiabetesandcardiacdisease.2 Children • Ensure staff have updated training in infection prevention and control
generally have been observed to experience a milder illness, although including personal protective equipment
perinatal exposure may be associated with substantial risk. The small • Planning at local and regional levels for a potential surge in the need
for critical care resources
numbersofpregnantwomeninfectedthusfarhavehadamildcourse,3
but limited cases make predictions about disease course uncertain; COVID-19–specific considerations
however, severe illness in pregnant women was a major concern with
Antiviral or immunomodulatory therapies are not yet proven effective
influenza A(H1N1)pdm2009. The median duration between onset of for treatment of COVID-19. Patients should be asked to participate
symptoms and ICU admission has been 9 to 10 days, suggesting a in clinical trials of supportive or targeted therapies.

gradual deterioration in the majority of cases.4 The most documented

reasonforrequiringintensivecarehasbeenrespiratorysupport,ofwhich
two-thirds of patients have met criteria for acute respiratory distress of ARDS: a syndrome characterized by acute onset of hypoxemic
syndrome (ARDS).2 respiratory failure with bilateral infiltrates. Evidence-based treatment
guidelines for ARDS should be followed, including conservative fluid
Differentiating From Other Diseases strategies for patients without shock following initial resuscitation, em-
Given the presence of a number of circulating respiratory viruses, dif- pirical early antibiotics for suspected bacterial co-infection until a spe-
ferentiating COVID-19 from other pathogens, particularly influenza, is cific diagnosis is made, lung-protective ventilation, prone positioning,
important and chiefly done using upper (nasopharyngeal) or lower andconsiderationofextracorporealmembraneoxygenationforrefrac-
(induced sputum, endotracheal aspirates, bronchoalveolar lavage) tory hypoxemia.5
respiratory tract samples for reverse transcriptase–polymerase chain In settings with limited access to invasive ventilation or prior to pa-
reactionandbacterialcultures.Therearesuggestivebutnonspecificra- tients developing severe hypoxemic respiratory failure, there may be
diographic changes, such as ground-glass opacities on computed a role for high-flow nasal oxygen or noninvasive ventilation.6 How-
tomography.2 Rapidaccesstodiagnostictestingresultsisapublichealth ever, the high gas flow of these 2 techniques is less contained than in
and clinical priority, allowing for efficient patient triage and implemen- the closed circuitry typical of invasive ventilators, which poses the risk
tation of infection control practices. of dispersion of aerosolized virus in the health care environment, such
as in the setting of a poorly fitting face mask. Determining the magni-
Clinical Management and Outcomes tude of this risk, and mitigation strategies, is a crucial knowledge gap.
Management of severe COVID-19 is not different from management Septic shock and specific organ dysfunction such as acute kidney
of most viral pneumonia causing respiratory failure (Figure). The injuryappeartooccurinasignificantproportionofpatientswithCOVID-
principal feature of patients with severe disease is the development 19–related critical illness and are associated with increasing mortality,

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 Clinical Review & Education JAMA Insights

with management recommendations following available evidence- sources. Furthermore, if access to lifesaving interventions such as
based guidelines.7 hospital beds, ventilators, extracorporeal membrane oxygenation,
While no antiviral or immunomodulatory therapies for COVID-19 or renal replacement therapy is likely to be strained, clear resource
have yet proven effective, a majority of severely ill patients described allocation policies should be determined by clinicians, policy mak-
to date have received numerous potentially targeted therapies— ers, the general public, and ethicists. These active preparation mea-
most commonly neuraminidase inhibitors and corticosteroids— sures can be organized well before large numbers of infected pa-
and a minority of patients have been enrolled in clinical trials. tients require hospital preparation.
While mortality among all infected patients may be in the range
of 0.5% to 4%,1 among patients who require hospitalization, mor- Major Knowledge Gaps
tality may be approximately 5% to 15%, and for those who become COVID-19 is a novel disease with an incompletely described clinical
critically ill, there is currently a wide mortality range, from 22% to course, especially for children and vulnerable populations. Risk fac-
62% in the early Hubei Province case series.2,4 The exact cause of tors for severe illness remain uncertain (although older age and co-
death is unclear at this point, with progressive hypoxia and multi- morbidity have emerged as likely important factors), the safety of
organ dysfunction being the presumed causes. Case-fatality pro- supportive care strategies such as oxygen by high-flow nasal can-
portions, both among all COVID-19 patients and among severely ill nula and noninvasive ventilation are unclear, and the risk of mortal-
patients, will likely become more precise and generalizable with in- ity, even among critically ill patients, is uncertain. There are no proven
creased surveillance to better clarify the number of individuals in- effective specific treatment strategies, and the risk-benefit ratio for
fected and as greater numbers of infections occur around the globe. commonly used treatments such as corticosteroids is unclear.
It is essential to learn as much as possible through observational
Protecting Patients and Health Care Workers studiesandclinicaltrialsacrossabreadthofpatientpopulationsandcare
Reducing the risk of nosocomial outbreak amplification through trans- settings. These should incorporate clear measurements of severity of
mission of virus to other patients and health care workers is of critical criticalillnesssothatoutcomescanberiskadjusted,andusesufficiently
importance.Maintainingappropriatedistancingofatleast2mbetween common outcome measures to combine data and validly compare ob-
patients with suspected or confirmed to have COVID-19, consideration servations across regions.8 Ideally, clinical trials should be structured to
of use of medical masks for symptomatic patients, and, ideally, admis- promote maximum learning from around the world, such as through
sion of patients with suspected disease to private rooms are important the use of master protocols or adaptive platform designs.9,10
considerations.Ensuringhospitalstaffarewelltrainedinstandard,con-
tact, and droplet infection prevention and control precautions, includ- Conclusions
ingtheuseofrelevantpersonalprotectiveequipment,isanimperative. In a very short period, health care systems and society have been
Clinicians involved with aerosol-generating procedures such as endo- severely challenged by yet another emerging virus. Preventing trans-
tracheal intubation and diagnostic testing using bronchoscopy should mission and slowing the rate of new infections are the primary goals;
additionally use airborne precautions, including N95 respirators or however, the concern of COVID-19 causing critical illness and death
equivalent face masks and face shields or goggles for eye protection. is at the core of public anxiety. The critical care community has enor-
mous experience in treating severe acute respiratory infections ev-
Surge Preparation ery year, often from uncertain causes. The foundation for care of se-
If increasing numbers of patients with COVID-19 develop severe ill- verely ill patients with COVID-19 must be grounded in this evidence
ness, plans should be made at local and regional levels for how to base and, in parallel, ensure that learning from each patient is maxi-
best manage the potential surge in the need for critical care re- mized to help those who will follow.

ARTICLE INFORMATION REFERENCES tilation in adult patients with acute respiratory

Author Affiliations: University of British Columbia, 1. Wu Z, McGoogan JM. Characteristics of and distress syndrome. Am J Respir Crit Care Med. 2017;
Vancouver, British Columbia, Canada (Murthy); important lessons from the coronavirus disease 2019 195(9):1253-1263.
Chinese University of Hong Kong, Hong Kong (COVID-19) outbreak in China. JAMA. Published online 6. Alraddadi BM, Qushmaq I, Al-Hameed FM, et al.
(Gomersall); Sunnybrook Hospital, University of February 24, 2020. doi:10.1001/jama.2020.2648 Noninvasive ventilation in critically ill patients with
Toronto, Toronto, Ontario, Canada (Fowler). the Middle East respiratory syndrome. Influenza
2. Wang D, Hu B, Hu C, et al. Clinical characteristics
Corresponding Author: Srinivas Murthy, MD, CM, Other Respir Viruses. 2019;13(4):382-390.
of 138 hospitalized patients with 2019 novel
MHSc, University of British Columbia, 4500 Oak St, 7. De Backer D, Dorman T. Surviving Sepsis
coronavirus-infected pneumonia in Wuhan, China.
Vancouver, BC V6H 3V4, Canada (srinivas.murthy@ Guidelines: a continuous move toward better care
JAMA. Published online February 7, 2020. doi:10.
cw.bc.ca). of patients with sepsis. JAMA. 2017;317(8):807-808.
1001/jama.2020.1585
8. COVID-19 case record form. Accessed March 2,
Published Online: March 11, 2020. 3. Chen H, Guo J, Wang C, et al. Clinical
2020. https://isaric.tghn.org/novel-coronavirus/
doi:10.1001/jama.2020.3633 characteristics and intrauterine vertical
9. World Health Organization. Master Protocol:
Conflict of Interest Disclosures: Dr Gomersall transmission potential of COVID-19 infection in nine
A Multi-center, Adaptive, Randomized Controlled
reported that his department has received funding pregnant women. Lancet. Published online February
Trial of the Safety and Efficacy of Investigational
to develop educational material from Getinge, 12, 2020. doi:10.1016/S0140-6736(20)30360-3
Therapeutics for the Treatment of COVID-19 in
Draeger Medical, Hamilton Medical, and Fisher & 4. Yang X, Yu Y, Xu J, et al. Clinical course and Hospitalized Patients. Published February 24, 2020.
Paykel. No other disclosures were reported. outcomes of critically ill patients with SARS-CoV-2 Accessed March 2, 2020. https://www.who.int/
pneumonia in Wuhan, China. Lancet Respir Med. blueprint/priority-diseases/key-action/novel-
Additional Contributions: We thank the
2020;S2213-2600(20)30079-5. coronavirus/en/
International Forum of Acute Care Trialists (InFACT)
for assistance. 5. Fan E, Del Sorbo L, Goligher EC, et al. An official 10. REMAP-CAP: A Randomized, Embedded,
American Thoracic Society/European Society of Multifactorial, Adaptive Platform Trial for
Intensive Care Medicine/Society of Critical Care Community-Acquired Pneumonia. Accessed March
Medicine clinical practice guideline: mechanical ven- 3, 2020. http://www.remapcap.org

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