Airway Hygiene in COVID-19 Pneumonia: Treatment Responses of 3 Critically Ill Cruise Ship Employees

Case series Patients: Male, 72-year-old • Male, 65-year-old • Male, 48-year-old Final Diagnosis: COVID-19 pneumonia Symptoms: Cough • dynpnea • fever Medication: — Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine • Microbiology and Virology • Pulmonology OBJECTIVE: Unusual clinical course BACKGROUND: COVID-19, the disease entity caused by the novel severe acute respiratory coronavirus 2 (SARS-CoV-2), continues to pose a major therapeutic challenge for clinicians. At present, an effective treatment regimen and vacci-nation has not been established. Many patients develop severe symptoms requiring endotracheal intubation and a prolonged stay in the Intensive Care Unit (ICU). In early postmortem examinations of COVID-19 patients, profuse viscous secretions were observed throughout the respiratory tract. Thus, oxygen supplementation without aggressive pulmonary hygiene management may be suboptimal. In the present case series, pulmonary hygiene management encompassed mucolytics, bronchodilators, and tracheal suctioning. We report 3 severe cases of COVID-19 pneumonia in cruise ship employees who were admitted to the ICU and responded to supportive mechanical ventilation and pulmonary hygiene management. CASE REPORTS: Three cruise ship employees with COVID-19 underwent endotracheal intubation and were admitted to the ICU for acute hypoxemic respiratory failure. Initial chest X-rays suggested multifocal pneumonia with superimposed acute respiratory distress syndrome (ARDS). A regimen of hydroxychloroquine, azithromycin, and dexamethasone was initiated on admission in all cases. Additionally, medications used for pulmonary hygiene were administered through a metered-dose inhaler (MDI) in line with the ventilator circuit. Endotracheal suctioning was performed prior to medication administration. The duration from endotracheal intubation to extubation ranged from 9 to 24 days. All 3 patients reached 30-day survival. CONCLUSIONS: The cases reported highlight the importance of the use of airway hygiene with mucolytics, bronchodilators, and tracheal suctioning for patients with COVID-19 pneumonia requiring ventilatory support.