University of Milan, Italy

Respiratory support strategy of severe failure caused by sars-cov-2 infection

CV: Giuseppe A Marraro is Distinguished Professor at Department of Pulmonary and Critical Care Medicine, Department of Neonatology and Pediatrics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China. Is Prof. Emeritus and Adjunct Professor at Center for Medical Simulation, DY Patil University, Navi Mumbai, India. He is associated to the “Healthcare Accountability Lab” at the University of Milan. He served as Chief of Department of Anesthesia and Intensive Care and Pediatric Intensive Care, Fatebenefratelli and Ophthalmiatric University Affiliated Hospital, Milan Italy; as President of the Italian Society of Anesthesia, Intensive Care, Emergency and Pain Society – SIARED.

His clinical and experimental scientific researches interests include Respiratory and Critical Care Medicine and Anesthesia in neonates, children and adults (e.g. protective lung ventilation strategy in human and animals; non-invasive ventilation; lung ultrasonography in children and neonate; biomarkers for lung diseases and pediatric sepsis; liquid ventilation; independent lung ventilation in pediatric age; clinical use of surfactant in lung pathologies in adults, pediatric age and neonates).

He acts as Associate Editor of Pediatric Critical Care Medicine and Member of the Editorial Boards and Reviewer of several scientific medical journals. He is authors/editor/co-author of 38 books, 7 scientific video-film; 300 scientific publications. He is deeply involved in basic and advanced education and training, and in the use of advance simulation systems in medical education.

He has been awarded with the Yandang Friendship Award and the West Lake Friendship Award. in China.

Abstract: Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 infection, is a systemic disease characterized by severe respiratory failure, similar to Acute Respiratory Distress Syndrome (ARDS).

The rapid spread of the COVID-19 pandemic on a global level has put national health systems in crisis, also highlighting considerable differences between countries in the proven effectiveness to deal with major emergencies, especially in the initial phase of the first pandemic wave.

COVID-19 has a great variability in severity ranging from a simple flu-like event with fever, cough, severe asthenia, shortness of breath up to severe ARDS.

The SARS-CoV-2 infection simultaneously infected a large number of patients and rapidly spread all over the world, also due to the initial lack of recognition of its severity which has led to dramatic consequences.

The severity and the very wide spread of the pandemic found everyone unprepared because, in addition to the symptomatic treatment, it was not known which treatments could be effective compared to others that were proposed from time to time. There has been enormous confusion in the treatments applied with extremely conflicting results in relation to the patients treated. Essentially there was a very wide use of O2, sometimes at high concentrations that could probably be toxic. Anti-inflammatory generics, antivirals, hydrochloroquine, plasma transfusion obtained from patients who had overcome the syndrome were used, as well to specific and in some cases traditional medicines in the countries where they are still used. The results on careful analysis were negative.

The WHO has defined the pharmacological treatments as certainly effective, resolving the great confusion that had arisen. Antipyretics have been described as useful in the initial stages and in home treatments. The use of O2 had to be supplemented at non-toxic dosages. In the advanced stages, non-invasive and invasive ventilatory support was indicated.

After the first autopsies it was revealed that the patients who died of severe SARS CoV-2 infection revealed not only the presence of diffuse alveolar damage consistent with ARDS but also with a higher thrombus burden in pulmonary capillaries. Following this evidence, the use of anticoagulants was suggested to avoid the formation of thrombus and facilitate their resolution.

Steroids that from the beginning had been widely used without any specific indication even in non-severe cases, were limited to advanced stage ARDS only.

The advanced stages of COVID-19 required hospitalization in ICU and in most cases support with non-invasive – continuous positive airway pressure (CPAP) through the use of Helmet and high flow nasal cannula (HFNC) – and invasive ventilation. The recommended ventilatory model has been the low tidal volume strategy, the appropriate level of positive end expiratory pressure (PEEP) and prone position.

The large number of patients who simultaneously required intensive care and artificial ventilation to treat the severe respiratory failure exerted on ICU a considerable pressure. Two main shortcomings were highlighted: lack of suitable spaces and mechanical ventilators for which it was necessary to proceed with the choice of patients to be hospitalized and ventilated in the ICU based on age and any associated pathologies.