Skip to main content

Care of Critically Ill Patients with COVID-19

Last Updated: May 12, 2020

Summary Recommendations
Summary Recommendations

Infection Control:

  • For health care workers who are performing aerosol-generating procedures on patients with COVID-19, the COVID-19 Treatment Guidelines Panel (the Panel) recommends using fit-tested respirators (N95 respirators) or powered air-purifying respirators rather than surgical masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) (AIII).
  • The Panel recommends that endotracheal intubation for patients with COVID-19 be done by health care providers with extensive airway management experience, if possible (AIII)
  • The Panel recommends that intubation be achieved by video laryngoscopy, if possible (CIII).

Hemodynamic Support:

  • The Panel recommends norepinephrine as the first-choice vasopressor (AII).

Ventilatory Support:

  • For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, the Panel recommends high-flow nasal cannula (HFNC) oxygen over noninvasive positive pressure ventilation (NIPPV) (BI).
  • In the absence of an indication for endotracheal intubation, the Panel recommends a closely monitored trial of NIPPV for adults with COVID-19 and acute hypoxemic respiratory failure for whom HFNC is not available (BIII).
  • For adults with COVID-19 who are receiving supplemental oxygen, the Panel recommends close monitoring for worsening respiratory status, and in the event intubation becomes necessary, that the procedure be performed by an experienced practitioner in a controlled setting (AII).
  • For mechanically ventilated adults with COVID-19 and acute respiratory distress syndrome (ARDS), the Panel recommends using low tidal volume (Vt) ventilation (Vt 4–8 mL/kg of predicted body weight) over higher tidal volumes (Vt >8 mL/kg) (AI).
  • For mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimized ventilation, the Panel recommends prone ventilation for 12 to 16 hours per day over no prone ventilation (BII).
  • For mechanically ventilated adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies, the Panel recommends a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the patient should be tapered off treatment (CIII).
  • There are insufficient data to recommend either for or against the routine use of extracorporeal membrane oxygenation for patients with COVID-19 and refractory hypoxemia (BIII).

Drug Therapy:

  • There are insufficient data for the Panel to recommend either for or against any immunomodulatory therapy in patients with severe COVID-19 disease (AIII).
  • In patients with COVID-19 and severe or critical illness, there are insufficient data to recommend empiric broad-spectrum antimicrobial therapy in the absence of another indication (BIII).
  • The Panel recommends against the routine use of systemic corticosteroids for the treatment of mechanically ventilated patients with COVID-19 without ARDS (BIII).
  • In mechanically ventilated adults with COVID-19 and ARDS, there are insufficient data to recommend either for or against corticosteroid therapy in the absence of another indication (CI).
  • In COVID-19 patients with refractory shock, low-dose corticosteroid therapy is preferred over no corticosteroid therapy (BII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion