key: cord-277590-u0uf88e7
authors: Gage, Ann; Higgins, Andrew; Lee, Ran; Panhwar, Muhammad Siyab; Kalra, Ankur
title: Reacquainting Cardiology With Mechanical Ventilation in Response to the COVID-19 Pandemic
date: 2020-03-27
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.03.007
sha: 
doc_id: 277590
cord_uid: u0uf88e7

nan

The incidence has been even higher in the Italian series, with up to 10% of infected patients in Lombardy developing ARDS (2) . It is likely that many American physicians will be called on to treat pneumonia, hypoxemic respiratory failure, and ARDS, regardless of their specialty.

ARDS is a life-threatening form of lung injury. This lung injury can be the result of primary pulmonary parenchymal injury such as pneumonia or aspiration or from a systemic process such as sepsis or trauma.

Increased capillary permeability leading to inflammation is the inciting factor for ARDS. Damage to the capillary endothelium and alveolar epithelium results in protein accumulation within the alveoli, activation of proinflammatory cytokines, and then pulmonary fibrosis. This cascade leads to loss of functional lung tissue. Chest radiography demonstrates bilateral opacities. As ARDS progresses, lung compliance decreases, hypoxemia ensues, and patients can progress to ventilator dependence (3, 4) .

In practice, ARDS is defined by the Berlin definition. blockade may also be considered (7).

It should be noted that mild ARDS may be managed with noninvasive forms of ventilation. However, during the present pandemic, modifications to usual critical care may be necessary. Given concern for viral transmission, current recommendations advise to 28 breaths/min); this may then be adjusted based on the patient's arterial pCO 2 ( Figure 1 ).

After initial stabilization, it is critical to appropriately titrate settings to minimize ventilator-induced lung injury. One of the most common methods for doing this is careful monitoring of the plateau pressure ( Figure 2) . Although the peak inspiratory pressure represents the pressure to which the proximal large airways are exposed, the plateau pressure is representative of the pressure present in the alveoli at end inspiration, and thus is an indicator of transpulmonary pressure, lung overdistention, and ventilator-induced lung injury. Plateau pressure is measured after a 0.5-to 1.0-s inspiratory pause maneuver. If the plateau pressure is >30 cm H 2 O, consider further reducing the delivered tidal volume.

It is also important to monitor the patient's driving pressure, or difference between the PEEP and plateau pressure, as increased driving pressures have been associated with higher mortality in ARDS (10).

With a basic understanding of these fundamentals, it is possible for all cardiologists to provide safe and effective care for our patients with COVID-19. As many of us prepare to use skill sets long forgotten, it will be important to remember to ask for help when needed. One of the few bright spots in this pandemic has been the resurgence of interdisciplinary team- 

Clinical characteristics of coronavirus disease 2019 in China

COVID-19 and Italy: what next?

Acute respiratory distress syndrome: advances in diagnosis and treatment

Acute respiratory distress syndrome: pathophysiology and therapeutic options

ARDS Definition Task Force

Acute respiratory distress syndrome: the Berlin definition

Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19)

Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis

Care for critically ill patients with COVID-19

for the ACC Critical Care Cardiology Working Group. Positive pressure ventilation in the cardiac intensive care unit

Driving pressure and survival in the acute respiratory distress syndrome

KEY WORDS acute respiratory distress syndrome, coronavirus, coronavirus disease-2019, mechanical ventilation