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(1) Nasal cannula or mask inhalation of oxygen
PaO2/Fi O2 Severe cases below 300 mmHg should be given oxygen therapy immediately
.
After receiving oxygen through a nasal cannula or mask, close observation for a short time (1~2 hours), if respiratory distress and/or hypoxemia do not improve, nasal high-flow oxygen therapy (HFNC) or non-invasive ventilation (NIV)
should be used.
(2) Nasal high-flow oxygen therapy or non-invasive ventilation
Pa O 2/FiO 2 Nasal high-flow oxygen therapy (HFNC) or non-invasive ventilation (NIV) should be given to less than 200 mmHg.
In patients receiving HFNC or NIV, it is recommended to perform prone ventilation at the same time, i.
e.
, awake prone ventilation, in the absence of contraindications, and the duration of prone therapy should be greater than 12 hours
per day.
Some patients are at high risk of failure with HFNC or NIV and require close observation for signs and symptoms
.
If there is no improvement in the condition after short-term (1~2 hours) treatment, especially after receiving prone therapy, hypoxemia still does not improve, or the respiratory frequency, tidal volume or inspiratory effort is too strong, etc.
, often indicates that HFNC or NIV treatment is not effective, and invasive mechanical ventilation therapy
should be carried out in time.
(3) Invasive mechanical ventilation
In general, Pa O 2/FiO 2 Patients with less than 150 mmHg, especially if inspiratory effort is significantly enhanced, should be considered for endotracheal intubation and invasive mechanical ventilation
.
However, in view of the atypical clinical manifestations of hypoxemia in some severe and critical cases, whether PaO2/FiO2 meets the standard should not be simply used as an indication for endotracheal intubation and invasive mechanical ventilation, but should be evaluated in real time based on the patient's clinical manifestations and organ function
。
It is important to note that delays in endotracheal intubation can be more harmful
.
Early and appropriate invasive mechanical ventilation is an important treatment for critical cases, and a lung-protective mechanical ventilation strategy
should be implemented.
Patients with moderate to severe acute respiratory distress syndrome, or when the FI2 of invasive mechanical ventilation is greater than 50%, recruitment manoeuvres can be used
, and the decision to repeat recruitment manoeuvres can be made based on the responsiveness of the recruitment manoeuvres.
It should be noted that some patients with novel coronavirus infection have poor lung remanoeuvre, and excessive PEEP should be avoided leading to barotrauma
.
(4) Airway management
strengthens airway humidification, it is recommended to use an active heating humidifier, and conditionally use loop heating guide wires to ensure the humidification effect; Closed suction and, if necessary, tracheoscopy; Actively carry out airway clearance treatment, such as vibration sputum evacuation, high-frequency thoracic oscillation, postural drainage, etc.
; In the case of oxygenation and hemodynamic stability, carry out passive and active activities as early as possible to promote sputum drainage and pulmonary rehabilitation
.
(5) Extracorporeal membrane oxygenation (ECMO)
ECMO initiation timing: under optimal mechanical ventilation conditions (Fi O2 ≥80%, tidal volume of 6 ml/kg ideal body weight, PEEP ≥5 cmH2O, and no contraindications), and protective ventilation and prone ventilation are not effective, and one of the following is met, should be considered as soon as possible to evaluate ECMO.
(1) PaO 2/FiO 2<50mmHg for more than 3 hours;<b21>
(2) PaO 2/FiO 2<80mmHg for more than 6 hours;<b21>
(3) Arterial pH < 7.
25 and PaC<b20>O2>60mmHg for more than 6 hours, and respiratory rate > 35 times/min;
(4) When the respiratory rate > 35 times/min, the arterial blood pH < 7.
2 and the plateau pressure > 30cmH2O
.
Critical cases that meet the indications for ECMO and have no contraindications should be started as soon as possible to avoid delays and poor prognosis
.
ECMO mode selection
.
Intravenous-venous ECMO (VV-ECMO) is the most commonly used method when respiratory support is only required; If breathing and circulation are required at the same time, venous-arterial ECMO (VA-ECMO) is used; VA-ECMO can use venous-arterial-venous ECMO (vav-ecmo
) when hypoxia in the brachiocephalic region occurs.
After the implementation of ECMO, the protective lung ventilation strategy
is strictly implemented.
Recommended initial settings: tidal volume< 4~6ml/kg ideal weight, platform pressure ≤ 25cm H2O, drive pressure <15cm H2O, PEEP5~15cm <b22>H2 O, respiratory rate 4~10 times/min, FiO 2<50%.
<b28>
Patients who have difficulty maintaining oxygenation or who have strong inspiratory effort, significant consolidation in gravity-dependent areas of both lungs, or who require airway secretion drainage should be actively prone ventilation
.
What should I do if a patient has a high fever while on emergency duty? Finding the cause is the most important thing! How to deal with emergencies is correct?
Severe allergic reaction rescue, is epinephrine preferred? How is it administered? Where to see the flow chart, treatment points, and summary of the most complete emergency drugs?
Open "Clinical Decision Assistant - Evidence-based Medicine"
to search for related disease names/drug names, and go directly to what you want to see with one click, all here! 👇 Download the decision assistant app, the guide is free at any time ~
References: [1] Diagnosis and treatment plan for new coronavirus infection (trial version 10).
▼▼▼Click to read the original article to download the App
For more guidelines for the diagnosis and treatment of common diseases in the emergency department, go to the "Clinical Decision Assistant App"!
(1) Nasal cannula or mask inhalation of oxygen
PaO2/Fi O2 Severe cases below 300 mmHg should be given oxygen therapy immediately
.
After receiving oxygen through a nasal cannula or mask, close observation for a short time (1~2 hours), if respiratory distress and/or hypoxemia do not improve, nasal high-flow oxygen therapy (HFNC) or non-invasive ventilation (NIV)
should be used.
(2) Nasal high-flow oxygen therapy or non-invasive ventilation
Pa O 2/FiO 2 Nasal high-flow oxygen therapy (HFNC) or non-invasive ventilation (NIV) should be given to less than 200 mmHg.
In patients receiving HFNC or NIV, it is recommended to perform prone ventilation at the same time, i.
e.
, awake prone ventilation, in the absence of contraindications, and the duration of prone therapy should be greater than 12 hours
per day.
Some patients are at high risk of failure with HFNC or NIV and require close observation for signs and symptoms
.
If there is no improvement in the condition after short-term (1~2 hours) treatment, especially after receiving prone therapy, hypoxemia still does not improve, or the respiratory frequency, tidal volume or inspiratory effort is too strong, etc.
, often indicates that HFNC or NIV treatment is not effective, and invasive mechanical ventilation therapy
should be carried out in time.
(3) Invasive mechanical ventilation
In general, Pa O 2/FiO 2 Patients with less than 150 mmHg, especially if inspiratory effort is significantly enhanced, should be considered for endotracheal intubation and invasive mechanical ventilation
.
However, in view of the atypical clinical manifestations of hypoxemia in some severe and critical cases, whether PaO2/FiO2 meets the standard should not be simply used as an indication for endotracheal intubation and invasive mechanical ventilation, but should be evaluated in real time based on the patient's clinical manifestations and organ function
。
It is important to note that delays in endotracheal intubation can be more harmful
.
Early and appropriate invasive mechanical ventilation is an important treatment for critical cases, and a lung-protective mechanical ventilation strategy
should be implemented.
Patients with moderate to severe acute respiratory distress syndrome, or when the FI2 of invasive mechanical ventilation is greater than 50%, recruitment manoeuvres can be used
, and the decision to repeat recruitment manoeuvres can be made based on the responsiveness of the recruitment manoeuvres.
It should be noted that some patients with novel coronavirus infection have poor lung remanoeuvre, and excessive PEEP should be avoided leading to barotrauma
.
(4) Airway management
strengthens airway humidification, it is recommended to use an active heating humidifier, and conditionally use loop heating guide wires to ensure the humidification effect; Closed suction and, if necessary, tracheoscopy; Actively carry out airway clearance treatment, such as vibration sputum evacuation, high-frequency thoracic oscillation, postural drainage, etc.
; In the case of oxygenation and hemodynamic stability, carry out passive and active activities as early as possible to promote sputum drainage and pulmonary rehabilitation
.
(5) Extracorporeal membrane oxygenation (ECMO)
ECMO initiation timing: under optimal mechanical ventilation conditions (Fi O2 ≥80%, tidal volume of 6 ml/kg ideal body weight, PEEP ≥5 cmH2O, and no contraindications), and protective ventilation and prone ventilation are not effective, and one of the following is met, should be considered as soon as possible to evaluate ECMO.
(1) PaO 2/FiO 2<50mmHg for more than 3 hours;<b21>
(2) PaO 2/FiO 2<80mmHg for more than 6 hours;<b21>
(3) Arterial pH < 7.
25 and PaC<b20>O2>60mmHg for more than 6 hours, and respiratory rate > 35 times/min;
(4) When the respiratory rate > 35 times/min, the arterial blood pH < 7.
2 and the plateau pressure > 30cmH2O
.
Critical cases that meet the indications for ECMO and have no contraindications should be started as soon as possible to avoid delays and poor prognosis
.
ECMO mode selection
.
Intravenous-venous ECMO (VV-ECMO) is the most commonly used method when respiratory support is only required; If breathing and circulation are required at the same time, venous-arterial ECMO (VA-ECMO) is used; VA-ECMO can use venous-arterial-venous ECMO (vav-ecmo
) when hypoxia in the brachiocephalic region occurs.
After the implementation of ECMO, the protective lung ventilation strategy
is strictly implemented.
Recommended initial settings: tidal volume< 4~6ml/kg ideal weight, platform pressure ≤ 25cm H2O, drive pressure <15cm H2O, PEEP5~15cm <b22>H2 O, respiratory rate 4~10 times/min, FiO 2<50%.
<b28>
Patients who have difficulty maintaining oxygenation or who have strong inspiratory effort, significant consolidation in gravity-dependent areas of both lungs, or who require airway secretion drainage should be actively prone ventilation
.
Where to learn more about emergency care?
What should I do if a patient has a high fever while on emergency duty? Finding the cause is the most important thing! How to deal with emergencies is correct?
Severe allergic reaction rescue, is epinephrine preferred? How is it administered? Where to see the flow chart, treatment points, and summary of the most complete emergency drugs?
Open "Clinical Decision Assistant - Evidence-based Medicine"
to search for related disease names/drug names, and go directly to what you want to see with one click, all here! 👇 Download the decision assistant app, the guide is free at any time ~
References: [1] Diagnosis and treatment plan for new coronavirus infection (trial version 10).
▼▼▼Click to read the original article to download the App
