Finally, the use of steroid therapy to control the hyper-inflammation is largely debated

Finally, the use of steroid therapy to control the hyper-inflammation is largely debated. and different healthcare settings, we think KU-55933 that our experience and our point of view can be helpful for countries and hospitals that are now starting to face the COVID-19 Rabbit polyclonal to ZNF490 outbreak. Elettrocardiogram, Do not intubate, Do not resuscitate Standard operating procedures of the COVID-19 HDU Initial assessment of patient A minimum bundle of assessments through a systematic approach is implemented around the COVID-19 HDU. Additional tests should be considered on a case-by-case basis according to clinical condition and specific comorbidities, see Table?2. Table 2 Minimum bundle of assessments that are performed on HDU admission and urinary antigen; blood cultures (preferably during fever)EKGChest-X ray if not performed in the last 3?daysLung ultrasoundLower extremity venous ultrasoundInferior vena cava ultrasound Open in a separate window High dependency unit, Computed tomography, Blood gas analysis, Methicillin-resistant Elettrocardiogram Respiratory support ? COVID-19 patients are stratified according to severity and type of ARF on HDU admission with the aim to set respiratory support on a single individual basis [17], observe Table?3. Table 3 Proposed respiratory support based on the severity of acute respiratory failure arterial pO2 divided by the portion (percent) of inspired oxygen, High-flow nasal cannula, Continuous positive airway pressure, portion (percent) of inspired oxygen, Non-invasive ventilation, Positive end-expiratory pressure COVID-19 is usually a very heterogeneous disease and the type and severity of ARF depends on the conversation among multiple factors including the time from symptoms onset and admission to HDU, the severity of the contamination, the host response, physiological reserve and comorbidities, and the ventilatory responsiveness of the patient to hypoxemia [9, 18, 19]. A systematic review and meta-analysis of 25 randomized control trials (RCTs) showed that a liberal oxygen strategy (SpO2 targets higher of 96%) is usually associated with increased risk of hospital mortality in acutely ill patients [20]. In the HDU FiO2 is usually settled with the aim of target SpO2 of 92C96%. Despite international guidelines recommending only cautious trials of NIV in immunocompetent patients with ARF due KU-55933 to community-acquired pneumonia (CAP), RCTs showed that the possible application of Positive End-expiratory Pressure (PEEP) in CAP patients is able to recruit alveoli leading to a rapid improvement in oxygenation [21C23]. However, NIV and CPAP should not delay endo-tracheal intubation in patients who could benefit of invasive ventilation [24]. In particular, intubation should be prioritized in patients treated with CPAP or NIV presenting with clinical indicators of excessive inspiratory efforts, to avoid excessive intrathoracic negative pressures and self-inflicted lung injury [25]. Levels of PEEP and pressure support during CPAP or NIV should be individualized to obtain the lowest level of support able to oxygenate the patient without increase the risk of both lung and cardiovascular side effects. A particular concern shall be given to high PEEP pressures considering the increase risk of pneumothorax/pneumomediastinum. Furthermore, high PEEP in a poorly recruitable lung tends to result in severe haemodynamic impairment and fluid retention [26]. This is the rationale for the implementation in the SOPs of the COVID-19 HDU of the zero end-expiratory pressure (ZEEP)-PEEP test to tailor PEEP level in each single patient [27]. Patient posture during NIV is crucial to optimize ventilation. In particular, slumped posture should be avoided and early mobilization for all those patients is usually motivated. Prone positioning or lateral position could be also considered in these patients according to imaging and clinical status [28, 29]. Preliminary evidences show improvements in oxygenation parameters with prone positioning in patients with COVID-19 receiving NIV or HFNC [30]. However, clinicians should be aware that prone positioning can be also harmful [31]. Indeed, prone positioning of patients with relatively high compliance results in a modest benefit at the price of a high demand KU-55933 for stressed human resources [32]. Close blood gas analysis (BGA) and clinical evaluation are performed after position changes to verify the advantages. Finally, all the medical devices for non-invasive respiratory support have a risk of droplet distributing [33, 34]. The risk of contamination spread is usually higher with HFNC (a surgical mask should be put on by the patient) and lower with helmet CPAP [34]. This is one of the reasons why.