Now, taking into account the accumulated certain experience of maintaining patients with a koronavirusny infection, it is considered that the intubation of a trachea and invasive ventilation of the lungs have to be used only in that case when less invasive techniques of treatment of respiratory insufficiency showed the inefficiency. It must be kept in mind that in the conditions of a pandemic and mass arrival of patients in many institutions with limited resources ensuring quality of artificial ventilation of the lungs will become a difficult task. It is connected not only with small quantity of beds in the intensive care units equipped with respiratory devices but also with the problems connected with infrastructure, maintenance of the equipment, human resources and training. Examples of problems: frequent need of reuse of disposable components, bad access to expendables, including warm and moisture exchangers, aspiration catheters, bad access to spare parts of respiratory devices and so on.
There is no sufficient information on the most suitable time for an intubation of hypoxemic patients with heavy COVID-19 now, it will also depend on the local potential for artificial ventilation of the lungs. It is considered that at a considerable part of rather young patients, the anoxemia (even at a saturation less than 88%) is rather well transferred and is not followed by heavy disorder of breath or exhaustion. Indications to an intubation should not be based only on one hypoxia, and it is be based on disorder of breath and the general condition of the patient rather. During an intubation viruliferous aerosols therefore the personnel have to use respirators of N95, FFP2, FFP3 type or others of equivalent quality can be generated and take additional precautionary measures for reduction of risk of infection. It is preferable to carry out an intubation with use of the manual video laryngoscope as it allows to increase distance between a mouth of the patient and the person of the doctor who is carrying out an intubation. However in conditions with limited resources, as a rule, the videolaringoskopiya will not be available.
Invasive ventilation of the lungs can save lives to patients with heavy disorder of breath. However, against the background of severe damage of lungs, it can also aggravate or even to cause injury of lungs, including a barotrauma, a volyumotravma, an atelektravma, a biotrauma and an oxytrauma. In recent years less attention it is given to use of higher PEEP for prevention of an atelektravma. Artificial ventilation of the lungs at patients with critical COVID-19 differs in some important aspects from patients with other reasons of the acute respiratory a distress-a syndrome (ARDS). Important difference in the lungs affected with COVID-19 is coexistence of strongly affected areas of the lungs adjacent to rather unaffected sites. Affected areas with an atelectasis do not open or very difficult open by means of procedures of discovery of lung volume and use of higher PEEP. Not affected areas remain safe and, thus, are subject to risk of restretching because of higher PEEP levels. Thus, at these patients of strategy of prevention of an atelektravma with use of higher PEEP levels can worsen a state. It is similarly offered individual by the strategy of artificial ventilation of the lungs according to phenotypes of ORDS which were repeatedly described. Artificial ventilation of the lungs has to be directed to prevention of the damages caused by a respirator, way of protection of the intact tissue of lung.
Following these principles, a number of authors offers a number of practical strategy for artificial ventilation of the lungs. These offers can change when over time more data on artificial ventilation of the lungs of patients with COVID-19 appear. It is recommended to apply the strategy of small respiratory volumes with restriction of respiratory volume to 6 ml/kg on ideal body weight. Also it is recommended to use low PEEP — no more than 10 cm of a water column and to be careful at use of higher PEEP. Besides, an important point is control of pressure on a breath. The easiest way of achievement of lower inspiratory pressure is a restriction of respiratory volumes. Adequate titration of PEEP can also render salutary effect on pressure on a breath. It is necessary to emphasize once again that it is preliminary recommendations and they can change in process of accumulation of information on a koronavirusny infection and methods of its treatment.
Very important point in ensuring adequate respiratory support of patients with a koronavirusny infection is use of position of the patient on a stomach (pron-position). The ventral decubitus can improve oxygenation of the patient and therefore found broad application for patients with a koronavirusny infection.