COVID-19 and respiratory medicine

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New American Thoracic Society Guidance

An American Thoracic Society-led international task force has released a guidance document to help clinicians manage COVID-19 patients in the face of a worldwide pandemic and “minimal empirical evidence to guide treatment”. The new guidance ‘COVID-19 interim guidance on management pending empirical evidence is published as an open access document on the Society’s website: thoracic.org.

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The task force suggestions will be reconsidered as relevant evidence, particularly randomised trials, are published.

The interim guidance, is available at: www.thoracic.org/covid/covid‐19‐guidance.pdf.

ECMO-plays a vital role

There is currently no vaccine or treatment for COVID-19 beyond supportive care, such as mechanical ventilation or, in severe cases, extracorporeal membrane oxygenation (ECMO) to maintain patients and provide a window for potential recovery. When demand far outpaces a hospital’s ability to provide highly specialised, resource-intensive therapies such as ECMO, physicians must be prepared to determine when and if to offer such support.

In ‘ECMO Resource Planning in the Setting of a Pandemic Respiratory Illness’, an open-access paper published in the Annals of the American Thoracic Society, ECMO physicians outline their approach for care.

“The key challenge in pandemic settings is to optimise resource utilisation so that patients are appropriately triaged and cared for within a hospital and throughout the larger health care system,” says Dr Steven Keller, senior author and ECMO physician (Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA). “This is a daunting task as it requires a level of planning and coordination not routine in our current system and is difficult to implement within a limited window for planning and without dedicated resources,” he says.

Dr Keller and his co-author suggest the following guidelines to help medical centres respond to patients’ needs as resources contract in the COVID-19 pandemic:

  • Mild surge – focus on increasing capacity:
    • develop criteria specific to pandemic for initiation and cessation of ECMO
    • obtain necessary equipment and expand capacity
    • collocate/regionalise ECMO patients
    • implement staffing protocols that allow for ECMO specialists/RNs to care for more patients based on acuity
    • collaborate with other local/regional ECMO centres.
  • Moderate surge – transition focus to determine allocation of scarce resources.
  • Major surge – limit or defer use of scarce resources.

“Planning for how to deploy these resources in advance will both optimise care for patients initiated on ECMO support as well as provide guidance for clinicians caring for patients in whom ECMO support is not an option in a resource-limited environment,” said Dr Keller.

The paper ‘ECMO Resource Planning in the Setting of Pandemic Respiratory Illness’ by Drs Raghu Seethala and Steven P Keller is available at: https://doi.org/10.1513/AnnalsATS.202003-233PS

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