Universität zu Köln

Pfeifer, M., Ewig, S., Voshaar, T., Randerath, W., Bauer, T., Geiseler, J., Dellweg, D., Westhoff, M., Windisch, W., Schoenhofer, B., Kluge, S. and Lepper, P. M. (2020). Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 German Respiratory Society. Pneumologie, 74 (6). S. 337 - 358. STUTTGART: GEORG THIEME VERLAG KG. ISSN 1438-8790

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Abstract

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI). The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies. This position paper is structured into the following five topics: 1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-2 2. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease 3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation 4. Non-invasive ventilation in ARI 5. Supply continuum for the treatment of ARI Key points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase. There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI. The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hufner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection. The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled. In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place. In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.

Item Type:	Journal Article
Creators:	Creators Email ORCID ORCID Put Code Pfeifer, M. UNSPECIFIED UNSPECIFIED UNSPECIFIED Ewig, S. UNSPECIFIED UNSPECIFIED UNSPECIFIED Voshaar, T. UNSPECIFIED UNSPECIFIED UNSPECIFIED Randerath, W. UNSPECIFIED UNSPECIFIED UNSPECIFIED Bauer, T. UNSPECIFIED UNSPECIFIED UNSPECIFIED Geiseler, J. UNSPECIFIED UNSPECIFIED UNSPECIFIED Dellweg, D. UNSPECIFIED UNSPECIFIED UNSPECIFIED Westhoff, M. UNSPECIFIED UNSPECIFIED UNSPECIFIED Windisch, W. UNSPECIFIED UNSPECIFIED UNSPECIFIED Schoenhofer, B. UNSPECIFIED UNSPECIFIED UNSPECIFIED Kluge, S. UNSPECIFIED UNSPECIFIED UNSPECIFIED Lepper, P. M. UNSPECIFIED UNSPECIFIED UNSPECIFIED
URN:	urn:nbn:de:hbz:38-331558
DOI:	10.1055/a-1157-9976
Journal or Publication Title:	Pneumologie
Volume:	74
Number:	6
Page Range:	S. 337 - 358
Date:	2020
Publisher:	GEORG THIEME VERLAG KG
Place of Publication:	STUTTGART
ISSN:	1438-8790
Language:	German
Faculty:	Unspecified
Divisions:	Unspecified
Subjects:	no entry
Uncontrolled Keywords:	Keywords Language EXTRACORPOREAL MEMBRANE-OXYGENATION; COMMUNITY-ACQUIRED PNEUMONIA; NONINVASIVE VENTILATION; DISTRESS-SYNDROME; MECHANICAL VENTILATION; INFLUENZA-VIRUS; PRESSURE VENTILATION; INFECTIOUS-DISEASES; LUNG INJURY; VIRAL LOAD Multiple languages Respiratory System Multiple languages
URI:	http://kups.ub.uni-koeln.de/id/eprint/33155