How severe COVID-19 infection is changing ARDS management
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EDITORIAL
How severe COVID‑19 infection is changing ARDS management Niall D. Ferguson1,2,3,4* , Tài Pham5,6,7 and Michelle Ng Gong8,9 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Plus ça change, plus c’est la même chose…. Over the last 6 months intensivists and non-intensivists around the world have been treating patients with acute respiratory distress syndrome (ARDS) brought on by COVID-19, often in extreme conditions with overwhelmed healthcare systems. As the first wave of the pandemic has passed in Europe and continues to progress in parts of North America, we pause to consider how severe COVID-19 infection is changing ARDS management and what the lasting implications might be for ARDS from other causes (Table 1). Our first thought is that COVID-19 is changing everything and nothing about ARDS management. Everything, in the sense that the thousands of severe COVID-19 patients have brought widespread attention from nonintensivists and the general public to the high mortality and management challenges of ARDS. This is refreshing as prior to the pandemic, ARDS was often under-recognized, even among the intensivists who cared for such patients [1]. But at the same time, nothing has changed as all of these ‘new-found’ therapies and supportive techniques are not actually new—they just have not been as well understood, applied or implemented before the pandemic. The foundation to ARDS management has been meticulous supportive care such as low tidal volume ventilation, and prone positioning in moderate-severe ARDS, both of which have been shown to reduce mortality. While proning had been reasonably well adopted in many European centres, its uptake in North America was poor, even in academic teaching centres, ranging from 8 to 15% *Correspondence: [email protected] 4 Toronto General Hospital Research Institute, 585 University Ave, 11‑PMB‑120, Toronto, ON M5G 2N2, Canada Full author information is available at the end of the article
of moderate-severe ARDS patients [1, 2]. Common reasons for deciding not to prone include a lack of comfort with the procedure, misconceptions that the patient may not be hypoxemic enough, and concerns about hemodynamics [3]. With COVID-19 surges, the large number of severely hypoxemic patients forced many intensive care units (ICUs) to discover that they can indeed provide care in the prone position for moderate-severe ARDS patients. Most centres have trained staff in how to prone and many have developed dedicated proning teams to facilitate this care [4]. Indeed, interest in proning COVID-19 patients has extended to non-intubated awake patients, [5] and proning of intubated and nonintubated patients has even been recognized in mainstream media (https://www.nytimes.com/2020/05/13/ health/coronavirus-proning-lungs.html). Even after the COVID-19 surge has passed, we are hopeful that the future threshold for proning in ARDS will remain much lower than it was in 2019. ARDS is known to be a heterogeneous syndrome with different sub-phenotypes that are characteri
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