The syndrome of acute respiratory insufficiency (ARDS) usually develops after the eclipse period lasting several hours or days after influence of a factor. The progressing respiratory insufficiency is connected with the pathological manifestations caused by disturbance of integrity of alveolar capillaries in lungs and transuding of proteinaceous transudate in alveolar space. The health worker has to distinguish heavy hypoxemic respiratory insufficiency in case of absence at the patient of the answer to a standard oxygen therapy or FIELDS and to be prepared for rendering expanded oxygen and ventilating support.
Patients of high risk of development of a syndrome of acute respiratory insufficiency (ARDS):
● age more than 60 years;
● associated diseases, such as diabetes mellitus, chronic disease of kidneys, chronic obstructive disease of lungs, bronchial asthma and hypertensia;
● high point on APACHE II scale;
● heavy anoxemia (PaO2: FiO2 of less than 100);
● shock (hypotension with hypoperfusion).
With COVID-19 specially trained, experienced specialist with use of precautionary measures of airborne spread of an infection has to carry out an endotracheal intubation of patients.
Carrying out IVL with lower respiratory volumes (from 4 to 8 ml/kg of rated mass of body/RMT) and lower inspiratory pressure is recommended (plateau pressure <30 smn2o). Bronkhoskopiya should not be seen off for the purpose of confirmation or an exception of the diagnosis of COVID-19. Bronkhoskopiya is recommended only in cases when she can change clinical treatment (in addition to COVID). If necessary conduct a research of tracheal aspirate or mini-bronchoalveolar lavage to a bronkhoskopiya.
From moderated to a severe form the central venous catheter and an arterial catheter has to be established to all patients with a syndrome of acute respiratory insufficiency (ARDS).
Deep sedation is necessary for control of activity of a respiratory center, achievement of target values of respiratory volume and an exception of desynchronization of the patient with the ventilator.
The conservative strategy of infusional therapy for patients with a syndrome of acute respiratory insufficiency (ARDS) is preferable option without hypoperfusion of fabrics.
Some authors point to existence of two phenotypes of acute respiratory insufficiency at the intubated sick COVID-19 and sick COVID-19 which are on mechanical ventilation. It is a phenotype of "L" (an atypical syndrome of acute respiratory insufficiency (ARDS)) which is characterized by low elasticity (high komplayens / extensibility of lungs), the low ventilating and perfusion index (that explains an anoxemia), low or normal density. lungs (only if a symptom of "opaque glass" on thorax KT) and a low rekrutabelnost of alveoluses (small amount of badly ventilated fabrics). The second phenotype — "H" (ARDS-like) which is characterized by high elasticity (high komplayens / extensibility of lungs), high return dumping (the fraction of minute warm emission perfusing not ventilated fabrics), high mass of lungs (bilateral infiltrates), a high rekrutabelnost of alveoluses (bigger amount of badly ventilated fabrics). Settings of the ventilator have to differ for each phenotype as the final and expiratory pressure (PEEP) at patients with komplayensom / extensibility of lungs without aberrations can make negative impact on a hemodynamics and lead to increase in a hyperinflation of lungs and a stress of lungs.
In case of a syndrome of acute respiratory insufficiency (ARDS) from moderated to a severe form from desynchronization of the patient with the ventilator contrary to appropriate sedation it is necessary to carry out at the earliest stage infusion of drugs for neuromuscular blockade, such as tsisatrakuriya or rokuroniya with possible lasting from 48 till 72 o'clock as necessary. Perhaps, bolyusny introduction with breaks prior to infusion.
Inhalation of pulmonary vazodilatator, such as inhalation nitrogen oxide (up to 20 ppm), can be the beginnings at the patient with a syndrome of acute respiratory insufficiency (ARDS) from average to heavy severity with the worsening hypoxia, with the termination in case of lack of the answer within 4 hours for use for other patients at whom the positive effect can be reached. At patients with the answer it is necessary to try to stop above-mentioned inhalation in 24–48 hours.
In case of continuation of an aggravation of symptoms of the patient despite the treatment stated above with a ratio P/F lower than 150, ventilation of the lungs in a pron-position within the first 24-48 hours after the beginning of a syndrome of acute respiratory insufficiency (ARDS) is recommended. Pron-pozitsiyu it is recommended to apply 12–16 hours a day; such position demands competence and experience from personnel for safe carrying out.