Respiratory Management of COVID 19

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Introduction

There is currently no treatment recommended for corona virus infections except for supportive care as required, in particular respiratory management. Approximately 14% of individuals who are diagnosed with COVID-19 develop severe disease that requires hospitalization and oxygen support, with only  5% of those who require admission to an intensive care unit . In these severe cases of COVID-19, main complications include acute respiratory distress syndrome (ARDS), sepsis and septic shock, multiorgan failure, including acute kidney injury and cardiac injury, which are more prevalent in at risk groups including older age (>70 years) and those with co-morbid disease such as cardiovascular disease, lung disease, diabetes and those who are immunosuppressed. In a small proportion of these, the illness may be severe enough to lead to death. Data currently suggests that illness is less common and usually less severe in younger adults.

Patients with severe disease often need oxygenation support. High-flow oxygen and noninvasive positive pressure ventilation have been used, but the safety of these measures is uncertain, and they should be considered aerosol-generating procedures that warrant specific isolation precautions. Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.

Clinical Syndromes Associated with COVID-19 

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Procedures at Risk of Contamination

Particular attention should be given during those interventions that place the health staff at greater risk of contamination for aerial dispersion of droplets. (Rachael)

Aerosol Generating Procedures (AGP)

Aerosols generated by medical procedures are one route for the transmission of the COVID-19 virus. For patients with suspected/confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential and minimised as much as possible. Where these procedures are indicated, they should be carried out in a single room with the doors shut, but preferably should be completed in a Negative Pressure Side Room. Only those healthcare staff who are needed to undertake the procedure should be present. Full PPE Equipment including a disposable, Fluid Repellent Surgical Gown, Gloves, Eye Protection and a FFP3 Respirator Mask should be worn by those undertaking the procedure and those in the room and good hand hygiene following the procedure. Hair cover should also be considered.

The following procedures are considered to be potentially infectious AGPs:

• Intubation, Extubation and Related Procedures;
• Tracheotomy/Tracheostomy Procedures;
• Manual Ventilation;
• Open Suctioning;
• Bronchoscopy;
• Non-Invasive Ventilation (NIV) e.g. Bi-level Positive Airway Pressure (BiPAP)and Continuous Positive Airway Pressure Ventilation (CPAP);
• Surgery and Post-Mortem Procedures in which high-speed devices are used;
• High-Frequency Oscillating Ventilation (HFOV);
• High-flow Nasal Oxygen (HFNO)
• Induction of Sputum; Note:Induction of sputum typically involves administration of nebulised saline to moisten and loosen respiratory secretions (this may be accompanied by chest physiotherapy such as percussion and vibration to induce forceful coughing. This may be required if lower respiratory tract samples are needed

Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include:

• Administration of Pressurised Humidified Oxygen;
• Administration of Medication via Nebulisation; Note: During nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks.

Physiotherapy Specific Aerosol Generating Techniques:

• Manual Techniques (e.g. Percussion/Manual Assisted Cough) that may lead to coughing and expectoration of sputum
• Use of Positive Pressure Breathing Devices (e.g. IPPB), Mechanical Insufflation-Exsufflation (Cough Assist) Devices, Intra/Extra Pulmonary High Frequency Oscillation Devices (e.g. the Vest / MetaNeb / Percussionaire etc.)
• Any Mobilisation or Therapy that may result in Coughing and Expectoration of Mucus
• Any Diagnostic Interventions that involve use of Video Laryngoscopy that can result in Airway Irritation and Coughing (e.g. Direct Visualisation during airway clearance techniques or when assisting Speech and Language Therapists perform Fibreoptic Endoscopic Evaluation of Swallow)

Decontamination

• Reusable (communal) non-invasive equipment must be decontaminated:
• between each patient and after patient use;
• after blood and body fluid contamination; and
• at regular intervals as part of equipment cleaning.

An increased frequency of decontamination should be considered for reusable non- invasive care equipment when used in isolation/cohort areas.

Equipment

• Reusable equipment should be avoided if possible; if used, it should be decontaminated according to the manufacturer’s instructions before removal from the room. If it is not possible to leave equipment inside a room then follow IPC Guidelines on Decontamination. This usually involves cleaning with neutral detergent, then a chlorine-based disinfectant, in the form of a solution at a minimum strength of 1,000ppm available chlorine (e.g. “Haz-Tab” or other brand).
• If possible use dedicated equipment in the isolation room. Avoid storing any extraneous equipment in the patient’s room
• Dispose of single use equipment as per clinical waste policy inside room
• Point of care tests, including blood gas analysis, should be avoided unless a local risk assessment has been completed and shows it can be undertaken safely
• Ventilators and mechanical devices (e.g. Cough Assist Machines) should be protected with a high efficiency viral-bacterial filter such as BS EN 13328-1.
• When using mechanical airway clearance filters should be placed at the machine end and the mask end before any expiratory or exhalation ports. Filters should be changed when visibly soiled or dependent on the filter used either after each use or every 24 hours and complete circuit changes should be undertaken every 72 hours (please follow trust guidance on this)
• Closed system suction should be used if patients are intubated or have tracheostomies
• Disconnecting a patient from mechanical ventilation should be avoided at all costs but if required the ventilator should be placed on standby
• Manual hyperinflation (bagging) should be avoided if possible and attempt ventilator recruitment manoeuvres where possible and required
• Water humidification should be avoided, and a heat and moisture exchanger should be used in ventilator circuits
• Disposable crockery and cutlery may be used in the patient’s room as far as possible to minimise the numbers of items which need to be decontaminated
• Any additional items such as Stethoscopes, Pulse Oximeters, Ultrasound Probes taken into a room will also need to be disinfected, regardless of whether there has been direct contact with the patient or not. This is due to the risk of environmental contamination of the equipment within the isolation room.

Patients Rooms

• If AGPs are undertaken in the patient’s own room, the room should be decontaminated 20 minutes after the procedure has ended (please follow trust IPC guidance on this also).
• If a different room is used for a procedure it should be left for 20 minutes, then cleaned and disinfected before being put back into use.
• Clearance of any aerosols is dependent on the ventilation of the room. In hospitals, rooms commonly have 12 to 15 air changes per hour, and so after about 20 minutes, there would be less than 1 per cent of the starting level (assuming cessation of aerosol generation).
• If it is known locally that the design or construction of a room may not be typical for a clinical space, or that there are fewer air changes per hour, then the local IPCT would advise on how long to leave a room before decontamination.

Prevention of Complications (WHO)

Reduced Days of Mechanical Ventilation:

●       Use weaning protocols that provide for the daily assessment of the spontaneous breathing capacity.

Reduce the Incidence of Ventilator-Associated Pneumonia

• Keep the patient in a semi-sitting position (30 - 45 degrees);
• Use a closed Suction System; Periodically Drain and Discard Condensate In Tubing;
• Use a new ventilation circuit for each patient, once the patient is ventilated change the circuit only if it is damaged or soiled, not routinely;
• Change Heat Moisture Exchanger when it malfunctions, when soiled, or every 5-7 days

Reduce the Incidence of Pressure Ulcers

• Turn Patient every 2 Hours

Reduce the Incidence of Intensive Care-Related Myopathy

• Mobilize the patient as soon as their condition allows and when safe to do so.

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