Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient

David M Maslove; Stephanie Sibley; J Gordon Boyd; Ewan C Goligher; Laveena Munshi; Isaac I Bogoch; Bram Rochwerg

doi:10.1016/j.chest.2021.10.011

Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient

Chest. 2022 Apr;161(4):989-998. doi: 10.1016/j.chest.2021.10.011. Epub 2021 Oct 13.

Authors

David M Maslove¹, Stephanie Sibley², J Gordon Boyd², Ewan C Goligher³, Laveena Munshi⁴, Isaac I Bogoch⁵, Bram Rochwerg⁶

Affiliations

¹ Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada; Kingston Health Sciences Centre, Kingston, ON, Canada. Electronic address: david.maslove@queensu.ca.
² Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada; Kingston Health Sciences Centre, Kingston, ON, Canada.
³ Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada.
⁴ Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Sinai Health System, Toronto, ON, Canada.
⁵ University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁶ Department of Medicine, McMaster University, Hamilton, ON, Canada; Juravinski Hospital, Hamilton, ON, Canada.

Abstract

Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.

Keywords: ARDS; COVID-19; ICU; complications; critical care; mechanical ventilation.

Publication types

Review

MeSH terms

COVID-19* / complications
Critical Illness / therapy
Diaphragm
Humans
Respiration, Artificial*