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| {{COVID-19}} | | {{COVID-19}} |
| {{SI}} | | {{SI}} |
| '''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''
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| '''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''
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| {{CMG}}; {{AE}} {{AyeshaFJ}}
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| ==Overview==
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| ARDS has been distributed over different phenotypes over the last decade. The management of COVID-19 related ARDS has been therefore led to different proposal for the management strategies that are stratified according to the type of phenotype. ARDS developed in 20 percent a median of eight days after the onset of symptoms; mechanical ventilation was implemented in 12.3 percent. <ref name="Wang Hu Hu Zhu p=1061">{{cite journal | last=Wang | first=Dawei | last2=Hu | first2=Bo | last3=Hu | first3=Chang | last4=Zhu | first4=Fangfang | last5=Liu | first5=Xing | last6=Zhang | first6=Jing | last7=Wang | first7=Binbin | last8=Xiang | first8=Hui | last9=Cheng | first9=Zhenshun | last10=Xiong | first10=Yong | last11=Zhao | first11=Yan | last12=Li | first12=Yirong | last13=Wang | first13=Xinghuan | last14=Peng | first14=Zhiyong | title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China | journal=JAMA | publisher=American Medical Association (AMA) | volume=323 | issue=11 | date=2020-03-17 | issn=0098-7484 | pmid=32031570 | pmc=7042881 | doi=10.1001/jama.2020.1585 | page=1061}}</ref> The mortality rate of COVID-19 related ARDS is higher in elderly patients. Given the importance of heterogeneity of ARDS profile , appropriate intervention at appropriate time is needed to help preventing the deterioration of lung function. Recent advances in RECOVERY trial has further strengthened this notion that the use of dexamethasone in patients on ventilator can reduce the mortality rate of patients by 1/3rd. The treatment of COVID-19 related ARDS is evolving with time and different treatment options are now available for the better management of ARDS.
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| ==Historical perspective==
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| * The [[novel]] [[coronavirus]] was named as the [[severe acute respiratory syndrome coronavirus-2]] ([[SARS-CoV-2]]) due to its high similarity to [[SARS-CoV]], which caused [[acute respiratory distress syndrome]] ([[ARDS]]) in 2002–2003.
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| * [[SARS-CoV-2]] virus primarily affects the [[respiratory]] [[system]] causing a wide variety of [[respiratory]] [[symptoms]] which can range from [[symptoms]] of [[lower respiratory tract infection]] to severe [[hypoxia]] to [[acute respiratory distress syndrome]] within a very short span of time.
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| * The [[acute respiratory distress syndrome]] ([[ARDS]]) is a common cause of [[morbidity]] and [[mortality]] in critically ill [[COVID-19]] [[infected]] [[patients]]. It is defined by the [[acute]] [[onset]] of [[noncardiogenic]] [[pulmonary]] [[edema]], [[hypoxaemia]] and the need for [[mechanical ventilation]]
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| ==Epidemiology and demographics==
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| * [[Incidence]] is higher in the elderly and much lower in children
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| * Higher [[mortality rate]] is seen in the elderly.
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| *A systematic review showed that ARDS occurred in 14% of patients (95% PI, 2 to 59%; 999/6322 patients; 23 studies).
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| ==Pathophysiology==
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| * [[ARDS]] arises as a [[complication]] of [[COVID-19]] [[infection]] due to [[acute]] [[inflammation]] of the [[alveolar space]] which prevents normal [[gas exchange]]. The increase in [[proinflammatory]] [[cytokines]] within the [[lung]] leads to recruitment of [[leukocytes]], further propagating the local [[inflammatory response]].<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246 }} </ref>
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| * The [[cytokine]] storm and the deadly uncontrolled [[systemic]] [[inflammatory]] response resulting from the release of large amounts of [[proinflammatory]] [[cytokines]] including [[interferons]] and [[interleukins]] and, [[chemokines]] by [[immune]] [[effector cells]] resulting in [[acute]] [[inflammation]] within the [[alveolar space]]. The [[exudate]] containing [[plasma proteins]], including [[albumin]], [[fibrinogen]], [[proinflammatory]] [[cytokines]] and [[coagulation factors]] will increase [[alveolar]]-[[capillary]] [[permeability]] and decrease the normal [[gas exchange]] and [[plasma proteins]], including [[albumin]], [[fibrinogen]], proinflammatory cytokines and coagulation factors.<ref name="pmidPMID: 19801579">{{cite journal| author=Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE| title=Activation and regulation of systemic inflammation in ARDS: rationale for prolonged glucocorticoid therapy. | journal=Chest | year= 2009 | volume= 136 | issue= 6 | pages= 1631-1643 | pmid=PMID: 19801579 | doi=10.1378/chest.08-2408 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19801579 }} </ref>
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| *The [[COVID-19]] [[patients]] with [[ARDS]] show elevated levels of [[IL-6]], [[IFN-a]], and [[CCL5]], [[CXCL8]], [[CXCL-10]] in [[serum]] as compared to those with the mild to moderate [[disease]].<ref name="pmidPMID: 32304191">{{cite journal| author=Tezer H, Bedir Demirdağ T| title=Novel coronavirus disease (COVID-19) in children | journal=Turk J Med Sci | year= 2020 | volume= 50 | issue= SI-1 | pages= 592-603 | pmid=PMID: 32304191 | doi=10.3906/sag-2004-174 | pmc=7195991 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32304191 }} </ref>
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| * This [[inflammatory]] [[process]] leads to the [[fibrin]] deposition in the [[air spaces]] and [[lung]] parenchyma and contributes to [[hyaline-membrane]] formation and subsequent [[alveolar]] [[fibrosis]].<ref name="pmidPMID: 2314423">{{cite journal| author=Bertozzi P, Astedt B, Zenzius L, Lynch K, LeMaire F, Zapol W | display-authors=etal| title=Depressed bronchoalveolar urokinase activity in patients with adult respiratory distress syndrome. | journal=N Engl J Med | year= 1990 | volume= 322 | issue= 13 | pages= 890-7 | pmid=PMID: 2314423 | doi=10.1056/NEJM199003293221304 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2314423 }} </ref>
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| * [[Patients]] [[infected]] with [[COVID‐19]] also exhibit [[coagulation]] [[abnormalities]].This [[procoagulant]] pattern can lead to [[acute respiratory distress syndrome]].<ref name="pmidPMID: 32302448">{{cite journal| author=Ranucci M, Ballotta A, Di Dedda U, Bayshnikova E, Dei Poli M, Resta M | display-authors=etal| title=The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome. | journal=J Thromb Haemost | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32302448 | doi=10.1111/jth.14854 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32302448 }} </ref>
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| ==Diagnosis==
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| ===Laboratory findings===
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| * [[Blood]] [[plasma]] has elevated levels of [[IL-6]], [[IL-1]], [[tumour necrosis factor-α]] ([[TNF α]]) and [[C-reactive protein]].<ref name="pmidPMID: 30872586">{{cite journal| author=Matthay MA, Zemans RL, Zimmerman GA, Arabi YM, Beitler JR, Mercat A | display-authors=etal| title=Acute respiratory distress syndrome. | journal=Nat Rev Dis Primers | year= 2019 | volume= 5 | issue= 1 | pages= 18 | pmid=PMID: 30872586 | doi=10.1038/s41572-019-0069-0 | pmc=6709677 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30872586 }} </ref>
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| * [[Thrombocytopenia]].<ref name="pmidPMID: 32178975">{{cite journal| author=Lippi G, Plebani M, Henry BM| title=Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. | journal=Clin Chim Acta | year= 2020 | volume= 506 | issue= | pages= 145-148 | pmid=PMID: 32178975 | doi=10.1016/j.cca.2020.03.022 | pmc=7102663 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32178975 }} </ref>
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| * Increased [[D-dimer]] levels. The elevated level of [[D-dimer]] is strongly associated with a higher [[mortality]] [[rate]].<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref>
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| * Increased [[fibrin]] [[degradation]] [[products]].<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref>
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| * Increased [[fibrinogen]].<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref><ref name="pmidPMID: 2455348">{{cite journal| author=Dowton SB, Colten HR| title=Acute phase reactants in inflammation and infection. | journal=Semin Hematol | year= 1988 | volume= 25 | issue= 2 | pages= 84-90 | pmid=PMID: 2455348 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2455348 }} </ref>
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| * [[Prothrombin time]] and [[activated partial thromboplastin time]] may be slightly elevated.<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref>
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| ====Imaging studies====
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| * [[Chest]] [[CT scan]] shows characteristic ground-glass opacities (GCO). This indicates the presence of [[exudate]] in the [[bronchoalveolar]] [[airspace]].<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246 }} </ref>
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| * [[Lung]] biopsy shows [[fibrin]] deposition.<ref name="pmidPMID: 32329246">{{cite journal| author=Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ| title=Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. | journal=J Thromb Haemost | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32329246 | doi=10.1111/jth.14872 | pmc=7264738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329246 }} </ref> <ref name="pmidPMID: 32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume= | issue= | pages= | pmid=PMID: 32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570 }} </ref>
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| ===Signs and Symptoms===
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| :*[[Dyspnea]]: The onset of [[dyspnea]] is relatively late around the 6th day.<ref name="pmidPMID: 32105632">{{cite journal| author=Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H | display-authors=etal| title=Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 5 | pages= 475-481 | pmid=PMID: 32105632 | doi=10.1016/S2213-2600(20)30079-5 | pmc=7102538 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32105632 }} </ref> <ref name="pmidPMID 32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume= | issue= | pages= | pmid=PMID 32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570 }} </ref>
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| :*[[Acute]] [[Hypoxemia]] due to [[respiratory failure]] is a dominant finding.<ref name="pmidPMID: 32228035">{{cite journal| author=Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D| title=COVID-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome. | journal=Am J Respir Crit Care Med | year= 2020 | volume= 201 | issue= 10 | pages= 1299-1300 | pmid=PMID: 32228035 | doi=10.1164/rccm.202003-0817LE | pmc=7233352 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32228035 }} </ref>
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| :*[[Hypercapnia]] could be present but it is [[rare]].<ref name="pmidPMID: 28740647">{{cite journal| author=Repessé X, Vieillard-Baron A| title=Hypercapnia during acute respiratory distress syndrome: the tree that hides the forest! | journal=J Thorac Dis | year= 2017 | volume= 9 | issue= 6 | pages= 1420-1425 | pmid=PMID: 28740647 | doi=10.21037/jtd.2017.05.69 | pmc=5506150 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28740647 }} </ref>
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| ==Treatment==
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| ==== Fluid and electrolytes management ====
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| * Studies have shown that in [[ARDS]], [[conservative]] [[fluid management]] may help [[patients]] by reducing [[oedema]] formation. <ref name="pmidPMID 16714767">{{cite journal| author=National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D | display-authors=etal| title=Comparison of two fluid-management strategies in acute lung injury. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 24 | pages= 2564-75 | pmid=PMID 16714767 | doi=10.1056/NEJMoa062200 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16714767 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=17080981 Review in: ACP J Club. 2006 Nov-Dec;145(3):69] </ref> <ref name="pmidPMID 25599463">{{cite journal| author=Grissom CK, Hirshberg EL, Dickerson JB, Brown SM, Lanspa MJ, Liu KD | display-authors=etal| title=Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*. | journal=Crit Care Med | year= 2015 | volume= 43 | issue= 2 | pages= 288-95 | pmid=PMID 25599463 | doi=10.1097/CCM.0000000000000715 | pmc=4675623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25599463 }} </ref>
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| * Conservative [[fluid]] [[management]] with [[buffered]] or [[non-buffered]] [[crystalloid]] is recommended for [[ARDS]] [[patients]].
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| * The [[conservative]] [[fluid]] strategy results in an increased number of [[ventilator]]-free days and a decreased length of [[ICU]] stay. However, its effect on [[mortality]] remains uncertain. <ref name="pmidPMID 27734109">{{cite journal| author=Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC | display-authors=etal| title=Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. | journal=Intensive Care Med | year= 2017 | volume= 43 | issue= 2 | pages= 155-170 | pmid=PMID 27734109 | doi=10.1007/s00134-016-4573-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27734109 }} </ref>
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| ==== Corticosteroids ====
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| * Recent [[studies]] have shown that the [[corticosteroid]] [[dexamethasone]] may reduce [[mortality]] of severe [[COVID-19]] [[patients]].<ref name="pmidPMID: 32551464">{{cite journal| author=Theoharides TC, Conti P| title=Dexamethasone for COVID-19? Not so fast. | journal=J Biol Regul Homeost Agents | year= 2020 | volume= 34 | issue= 3 | pages= | pmid=PMID: 32551464 | doi=10.23812/20-EDITORIAL_1-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32551464 }} </ref>
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| *In England, a non-peer-reviewed [[randomized]] [[trial]] was issued as a press release which suggested that [[dexamethasone]] has a potential survival benefit in [[hospitalized]] [[COVID-19]] [[patients]] requiring [[oxygen]].<ref>{{cite web |url=https://www.gov.uk/government/news/world-first-coronavirus-treatment-approved-for-nhs-use-by-government |title=World first coronavirus treatment approved for NHS use by government - GOV.UK |format= |work= |accessdate=}}</ref>
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| * The Society of Critical Care Medicine (SCCM) provided a weak conditional [[recommendation]] in the favor of [[glucocorticoids]] in [[patients]] with [[COVID-19]] who have severe [[ARDS]] with a [[partial]] [[arterial pressure]] of [[oxygen]]/[[fraction]] of [[inspired]] [[oxygen]] [[PaO2]]:[[FiO2]]] <100 mmHg). This recommendation suggests benefit in [[patients]] with moderate to severe [[ARDS]] which is [[refractory]] to low [[tidal volume]] [[ventilation]].<ref name="pmidPMID 28940011">{{cite journal| author=Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A | display-authors=etal| title=Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. | journal=Intensive Care Med | year= 2017 | volume= 43 | issue= 12 | pages= 1751-1763 | pmid=PMID 28940011 | doi=10.1007/s00134-017-4919-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28940011 }} </ref>
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| ====Mechanical Ventilation====
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| * [[Mechanical ventilation]] along with [[supportive]] [[therapies]] are the mainstay of [[treatment]] of [[ARDS]].<ref name="pmidPMID: 23825769">{{cite journal| author=Fanelli V, Vlachou A, Ghannadian S, Simonetti U, Slutsky AS, Zhang H| title=Acute respiratory distress syndrome: new definition, current and future therapeutic options. | journal=J Thorac Dis | year= 2013 | volume= 5 | issue= 3 | pages= 326-34 | pmid=PMID: 23825769 | doi=10.3978/j.issn.2072-1439.2013.04.05 | pmc=3698298 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23825769 }} </ref>
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| * [[Invasive]] [[mechanical ventilation]] (ie, [[ventilation]] via an [[endotracheal tube]] or [[tracheostomy]] with [[breaths]] delivered by a [[mechanical ventilator]]) is preferred for [[patients]] with [[ARDS]], particularly those with [[moderate]] or [[severe]] [[ARDS]] (ie, [[arterial]] [[oxygen]] [[tension]]/[[fraction]] of [[inspired]] [[oxygen]] [[PaO2]]/[[FiO2]] ≤200 mmHg on [[positive end-expiratory pressure]] ([[PEEP]]) ≥5 cm [[H2O]]).<ref>{{cite web |url=https://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf?ua=1 |title=www.who.int |format= |work= |accessdate=}}</ref>
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| * It is recommended to use [[low]] [[tidal volume]] [[ventilation]] ([[LTVV]]) with 4 to 8 mL/kg predicted body weight [PBW]. Several meta-analyses and randomized trials that report a mortality benefit from LTVV in patients with ARDS.<ref name="pmidPMID: 27035237">{{cite journal| author=Weiss CH, Baker DW, Weiner S, Bechel M, Ragland M, Rademaker A | display-authors=etal| title=Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome. | journal=Crit Care Med | year= 2016 | volume= 44 | issue= 8 | pages= 1515-22 | pmid=PMID: 27035237 | doi=10.1097/CCM.0000000000001710 | pmc=4949102 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27035237 }} </ref>
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| * The aim is to maintain [[oxygen]] [[saturation]] between 90% to 96%. The [[severe]] [[hypoxemia]] of the [[COVID-19]] [[ARDS]] best responds when [[Positive end-expiratory pressure]] ([[PEEP]]) is high with [[Pplat]] ≤30 cm H2O. It is beneficial if the [[physician]] starts with higher than usual levels of [[PEEP]] (10 to 15 cm H2O).<ref>{{cite web |url=https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf |title=www.who.int |format= |work= |accessdate=}}</ref>
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| *
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| ==== Anticoagulant or thrombolytic therapy ====
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| * [[Fibrinolytic drugs]] such as [[tissue-type plasminogen activator]] ([[tPA]]) degrade pre-existing [[fibrin]] in the [[lungs]].<ref name="pmidPMID: 32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=PMID: 32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref>
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| * [[Nebulizer]] [[plasminogen activators]] may provide more targeted therapy to degrade [[fibrin]] and improving [[oxygenatio]]n in critically ill patients. It is in Phase II of the [[clinical trial]].
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| ==Prevention==
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| * The [[ARDS]] [[patients]] have an increased [[risk]] of [[hospital]]-associated [[venous thromboembolism]] ([[VTE]]).<ref>{{cite web |url=https://b-s-h.org.uk/media/18171/th-and-covid-25-march-2020-final.pdf |title=b-s-h.org.uk |format= |work= |accessdate=}}</ref>
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| * Due to this reason, it is advised to take [[low molecular weight heparin]] ([[LMWH]]) [[prophylactically]] in [[patients]] who do not have the contraindications. Studies have shown that the [[heparin]], either unfractionated or [[LMWH]], can also reduce [[inflammatory]] [[biomarkers]] hence could help in reducing the [[inflammation]].<ref name="pmidPMID: 32338827">{{cite journal| author=Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M | display-authors=etal| title=ISTH interim guidance on recognition and management of coagulopathy in COVID-19. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 5 | pages= 1023-1026 | pmid=PMID: 32338827 | doi=10.1111/jth.14810 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32338827 }} </ref>
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| ==References==
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| {{Reflist|2}}
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