Treatment of COVID-19 Pneumonia in Critically Ill Patients Requiring High-Flow Oxygen, NIV, Mechanical Ventilation, or ECMO
Critically ill patients with COVID-19 pneumonia — those whose respiratory failure demands high-flow oxygen, noninvasive ventilation (NIV), invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) — require a management approach distinct from less severe hospitalised cases.
Clinical Scenario
This protocol targets hospitalised patients with COVID-19 whose illness meets the threshold of critical illness: requiring high-flow oxygen, noninvasive ventilation, invasive mechanical ventilation, or ECMO. Corticosteroids are a cornerstone of care in this population per current guideline recommendations.
Treatment Approach — Partial Overview
Beyond corticosteroids, the evidence-based approach for this critically ill population involves adding an immunomodulatory agent — from either the interleukin-6 inhibitor class or the Janus kinase inhibitor class — with agent selection guided by clinical factors and availability. The full selection algorithm, preferred agents, and situational decision rules are in the complete protocol.
References
DOI: 10.1093/cid/ciac724
- Among hospitalized critically ill patients with COVID-19, the IDSA guideline panel recommends dexamethasone rather than no dexamethasone.
- Critical illness is defined as patients on mechanical ventilation and extracorporeal membrane oxygenation (ECMO).
- Among hospitalized adults with progressive severe or critical COVID-19 who have elevated markers of systemic inflammation, the IDSA guideline panel suggests tocilizumab in addition to standard of care (ie, steroids) rather than standard of care alone.
- 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.
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