What is the treatment for COVID-19 with respiratory distress requiring oxygen therapy in the Intensive Care Unit (ICU) in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

For a COVID-19 patient with respiratory distress requiring oxygen in the ICU who has a history of COPD, treatment should include corticosteroids, such as dexamethasone, as the panel recommends offering treatment with corticosteroids for patients with COVID-19 requiring oxygen, noninvasive ventilation, or invasive mechanical ventilation 1. The treatment approach should prioritize minimizing complications and optimizing outcomes, considering the patient's history of COPD. Key considerations include:

• Corticosteroids: Dexamethasone 6 mg daily for up to 10 days is recommended, as it has been shown to reduce mortality and improve outcomes in COVID-19 patients requiring oxygen therapy 1.
• Oxygen therapy: should be titrated to maintain SpO2 between 88-92% (lower than typical targets due to COPD) to avoid hyperoxia and minimize lung damage.
• Bronchodilator therapy: should be continued with short-acting beta-agonists like albuterol via metered-dose inhaler with spacer or nebulizer (if aerosol precautions are in place) every 4-6 hours, and long-acting bronchodilators if previously prescribed.
• Anticoagulation: prophylactic anticoagulation with enoxaparin 40 mg daily (adjust for renal function and weight) should be provided unless contraindicated, as the panel recommends offering a form of anticoagulation to hospitalized patients with COVID-19 1.
• Noninvasive ventilatory support: high-flow nasal cannula or non-invasive ventilation should be tried before intubation, with careful attention to avoiding auto-PEEP in COPD patients, as suggested by the panel 1.
• IL-6 receptor antagonist monoclonal antibody therapy: may be considered, as the panel suggests offering IL-6 receptor antagonist monoclonal antibody therapy to hospitalized patients with COVID-19 requiring oxygen or ventilatory support, although the evidence is conditional and of low quality 1. It is essential to note that the treatment approach should be individualized, and the patient's response to therapy should be closely monitored. The use of other therapies, such as remdesivir, should be considered on a case-by-case basis, taking into account the patient's disease severity and underlying comorbidities. Ultimately, the goal of treatment is to minimize morbidity, mortality, and improve quality of life, and the approach should be guided by the most recent and highest-quality evidence available.

From the FDA Drug Label

The recommended total treatment duration for hospitalized patients requiring invasive mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO) is 10 days The recommended treatment duration for hospitalized patients not requiring invasive mechanical ventilation and/or ECMO is 5 days.

The treatment for COVID-19 with respiratory distress requiring oxygen therapy in the Intensive Care Unit (ICU) in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD) is remdesivir (IV).

• The recommended dosage is a single loading dose of 200 mg on Day 1 via intravenous infusion followed by once-daily maintenance doses of 100 mg from Day 2 via intravenous infusion.
• The treatment course should be initiated as soon as possible after diagnosis of symptomatic COVID-19 has been made.
• The recommended total treatment duration is 5-10 days, depending on the severity of the disease and the need for invasive mechanical ventilation and/or ECMO 2.

From the Research

Treatment for COVID-19 with Respiratory Distress

The treatment for COVID-19 with respiratory distress requiring oxygen therapy in the Intensive Care Unit (ICU) in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD) involves several strategies, including:

• Non-invasive oxygenation strategies such as high-flow nasal cannula oxygen therapy (HFNC) and non-invasive positive pressure ventilation (NPPV) 3, 4
• Prone ventilation of nonintubated patients, which is associated with improvement in oxygenation, but its impact on clinical outcome remains unclear 5
• Standard critical care measures, including prone mechanical ventilation, avoidance of excessive tidal volumes, conservative fluid management, antibiotic stewardship, and early evaluation for extracorporeal membrane oxygenation (ECMO) 5
• Use of dexmedetomidine as a sedative to improve compliance with non-invasive ventilation (NIV) in patients with COVID-19 and COPD 6

Non-Invasive Oxygenation Strategies

Non-invasive oxygenation strategies have been shown to be effective in managing acute respiratory failure in COVID-19 patients, including those with COPD. These strategies include:

• High-flow nasal cannula oxygen therapy (HFNC), which has been associated with improved survival and reduced need for intubation 3, 4
• Non-invasive positive pressure ventilation (NPPV), which has been shown to be effective in managing acute respiratory failure in COVID-19 patients, but its effectiveness and risk of viral spread are unclear 3
• Awake proning, which is an emerging strategy to optimize the management of patients with COVID-19 acute respiratory failure, but its benefits have yet to be assessed in properly designed clinical research 3

Management of COVID-19 ARDS without Invasive Mechanical Ventilation

Management of COVID-19 acute respiratory distress syndrome (ARDS) without invasive mechanical ventilation is feasible, and high-flow nasal cannula (HFNC) has been shown to be effective in managing ARDS without the need for intubation 7. The use of HFNC has been associated with improved outcomes, including reduced mortality and length of stay in the ICU 7, 4.