Managing Severe Hypoxic Respiratory Failure in COVID-19

PURPOSE OF REVIEW: Adult respiratory distress syndrome is a life-threatening complication from severe COVID-19 infection resulting in severe hypoxic respiratory failure. Strategies at improving oxygenation have evolved over the course of the pandemic. RECENT FINDINGS: Although non-invasive respiratory support reduces the need for intubation, a significant number of patients with COVID-19 progress to invasive mechanical ventilation. Once intubated, a lung protective ventilation strategy should be employed that limits tidal volumes to 6 ml/kg of predicted body weight and employs sufficient positive end-expiratory pressure to maximize oxygen delivery while minimizing the fraction of inspired oxygen. Intermittent prone positioning is effective at improving survival, and there is a growing body of evidence that it can be safely performed in spontaneously breathing patients to reduce the need for invasive mechanical ventilation. Inhaled pulmonary vasodilators have not been shown to improve survival or cost-effectiveness in COVID-19 and should be used selectively. SUMMARY: Finally, the best outcomes are likely achieved at centers with experience at severe ARDS management and protocols for escalation of care.