Scientific Letter
When success means focusing on the oxygen delivery. A case of conventional management of severe hypoxemia in SARS-CoV-2
Cuando el tratamiento adecuado consiste en evaluar el aporte de oxígeno. Manejo convencional de la hipoxemia severa en un paciente con SARS-CoV-2
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A case of conventional management of severe hypoxemia in SARS-CoV-2" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "379" "paginaFinal" => "380" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.L. Franqueza, E. Rosas, A.-M. Ioan, A. Durante-López, C. Pérez-Calvo, A. Santos" "autores" => array:6 [ 0 => array:3 [ "nombre" => "J.L." "apellidos" => "Franqueza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Rosas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A.-M." "apellidos" => "Ioan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." 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"apellidos" => "Santos" "email" => array:1 [ 0 => "asantosviedo@yahoo.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Intensive Care Medicine Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuando el tratamiento adecuado consiste en evaluar el aporte de oxígeno. Manejo convencional de la hipoxemia severa en un paciente con SARS-CoV-2" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">SARS-CoV-2 challenged ICU doctors’ ability to support patients with acute respiratory insufficiency. This was due to both the unexpectedly high rate of admissions and the severity of these patients. Through this case we would like to highlight the physiology guided management of a patient with profound hypoxemia. In spite of an apparently life threatening condition this patient had a good course with conventional management guided by invasive hemodynamic monitoring.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 46 years old male was admitted to the ICU with presumptive diagnosis of SARS-CoV-2. Respiratory symptoms had started 10 days before admission to the emergency room. Due to hypoxemia and tachypnea as well as an X-ray with bilateral infiltrates, the patient was early transferred to ICU. Support with high flow oxygen was started but escalation to invasive mechanical ventilation (MV) was required due to persistent hypoxemia. Due to a PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg despite FiO<span class="elsevierStyleInf">2</span> 1 (with protective mechanical ventilation settings PEEP 10 cmH<span class="elsevierStyleInf">2</span>O, tidal volume 6<span class="elsevierStyleHsp" style=""></span>ml/kg, plateau pressure 20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O) the patient was subjected to prone positioning therapy. The patient showed no change in respiratory mechanics during prone positioning but a slight improvement in oxygenation was observed. He completed a 16<span class="elsevierStyleHsp" style=""></span>h prone therapy session. Once in supine, oxygenation was severely deteriorated again with a PaO<span class="elsevierStyleInf">2</span>/FIO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mmHg hence extracorporeal membrane oxygenation (ECMO) therapy was proposed.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Additionally, he underwent invasive monitoring with a Swan-Ganz catheter. The patient showed moderate pulmonary hypertension (PASP 45<span class="elsevierStyleHsp" style=""></span>mmHg, PVRi 388<span class="elsevierStyleHsp" style=""></span>dyn<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a>), cardiac index 3.5<span class="elsevierStyleHsp" style=""></span>l<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and a preserved mixed blood oxygen saturation around 75%. These data were complemented with a transthoracic echocardiogram that showed no right ventricular (RV) dysfunction (which was concordant with a pulmonary artery pulsatility index<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.7), preserved left ventricular function and no signs of hypovolemia. Based on the preserved RV function and an adequate oxygen delivery with protective MV settings the decision of starting ECMO was postponed. Prone positioning sessions were continued up to a number of 5 and during the following days both the patient's lung function (which was more prominent in prone) as well as pulmonary hemodynamics progressively improved. The patient was extubated 2 weeks later.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During times of health services overwhelming, the selection of patients who will benefit from therapies related with a high consumption of resources should be carefully and efficiently performed. In the ICU one of these therapies is ECMO. There are doubts about the long term prognosis of patients with SARS-CoV-2 who develop severe hypoxemia despite the gentlest MV. Besides this, the physiology of the patient with SARS-CoV-2 has been proposed to be different from typical ARDS<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>: (1) A high proportion of them have good compliance (Gatinnoni's phenotype L) and in consequence management with low PEEP is recommended and (2) they show a blunted pulmonary vasoconstriction. Also, at least in our experience a low rate of systemic hemodynamic involvement is seen. Such differences could affect the indications of ECMO in these patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Respiratory ECMO is indicated to ensure oxygen delivery in patients in whom this cannot be reached under protective MV settings.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Other indications or goals are at least doubtful. Following this reasoning, comparing with typical ARDS, for the same arterial oxygen content, probably a lower proportion of SARS-CoV-2 patients would be subsidiaries of ECMO. A high compliance in a patient managed with relatively low PEEP could make it easier to reach safe settings including low plateau pressure, low driving pressure and tidal volume around 6<span class="elsevierStyleHsp" style=""></span>ml/kg<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a>. If we put this altogether with the decreased pulmonary vascular response to hypoxia, a low prevalence of RV failure could be expected. Finally, in the absence of RV dysfunction, patients with preserved left ventricle function can maintain a cardiac output enough to keep an adequate oxygen delivery. Therefore, deciding starting ECMO based only on PaO<span class="elsevierStyleInf">2</span> may not be adequate to cover the entire physiologic process in some patients with severe respiratory insufficiency in the context of COVID-19. This resolution should be adjusted to the current recommendations regarding the availability of resources.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Another important finding of this case is the apparently low O<span class="elsevierStyleInf">2</span> extraction which could be compatible with low systemic involvement at least at the disease stage at which the patient was. Also this could be due to the adequate sedation and the use neuromuscular blockade. In this context we would like to highlight that oxygen delivery depends essentially on cardiac output, hemoglobin concentration and SaO<span class="elsevierStyleInf">2</span>. Therefore in patients without risk of low cardiac output, taking into account SaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> instead of PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> could be a better index when taking the decision of escalating toward therapies such as ECMO.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, we would like to remark that despite the severity of the hypoxemia in this patient, he did improve with conventional therapies. Moreover, in spite of the doubts regarding the usefulness of prone positioning in the presence of good compliance, the patient's improvement was initially more evident with this approach. This could be due to a more marked dependence of pulmonary perfusion on gravity when hypoxic vasoconstriction is blunted. From this point of view prone positioning could be helpful in keeping the patient safe while waiting for the lung to heal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, through this case we would like to remark the importance of oxygen delivery in the management of patients with SARS-CoV-2 as this pathology could behave differently from typical ARDS. In this line of thought we recommend to be patient as long as we are able to reach the combination of protective MV settings and adequate peripheral oxygenation. This therapeutic attitude could contribute to a decrease in the necessity of more resource consuming therapies, which should be allocated following recommendations that take into account their scarcity during the pandemic, as pointed out by specific guidelines.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Authors have nothing to disclosure.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.H. 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Catalán González" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2020.03.006" "Revista" => array:2 [ "tituloSerie" => "Med Intens" "fecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004500000006/v1_202107200621/S2173572721000825/v1_202107200621/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004500000006/v1_202107200621/S2173572721000825/v1_202107200621/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572721000825?idApp=WMIE" ]
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