Treatment of Critical COVID-19 Requiring High-Flow Oxygen or Noninvasive Ventilation
Critical COVID-19 represents the most severe end of the disease spectrum. This protocol addresses patients who require high-flow oxygen, noninvasive ventilation (NIV), invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). End-organ dysfunction, including acute respiratory distress syndrome (ARDS), may be present.
Critically ill patients with COVID-19 include those on high-flow oxygen or noninvasive ventilation, as well as those requiring mechanical ventilation and ECMO. This protocol is specific to this critical-illness threshold and the management decisions it triggers.
Corticosteroid therapy is central to managing critically ill COVID-19 patients. In those with elevated inflammatory markers — common across this population — an additional immune-modulating agent targeting the inflammatory pathway is recommended alongside corticosteroids.
References
DOI: 10.1093/cid/ciac724
- Critical illness is defined as patients on mechanical ventilation and extracorporeal membrane oxygenation (ECMO).
- Critical COVID-19 needing high-flow oxygen or noninvasive ventilation
- Among hospitalized critically ill patients with COVID-19, the IDSA guideline panel recommends dexamethasone rather than no dexamethasone.
- In critically ill patients, dexamethasone 6 mg/day is preferred, but doses up to 20 mg/day can be used if indicated for other reasons.
- Hydrocortisone 50 mg IV every 6 hours is an alternative that has also been studied.
- In addition to corticosteroids, we recommend using either IL-6 inhibitors (tocilizumab preferred over sarilumab) or JAK inhibitors (baricitinib preferred over tofacitinib) in patients who have elevated inflammatory markers (eg, CRP), which most critically ill patients with COVID-19 have.
- In situations where IL-6 inhibitors are not available, baricitinib can be used in mechanically ventilated patients, as a small trial showed a mortality benefit in this population.