Since December 2019, a severe acute respiratory infection (SARI) caused by 2019 novel
coronavirus (SARS-CoV-2), began to spread from Wuhan to all of China [1, 2], and indeed
the world. As of Feb 10, 2020, there are more than 40,000 confirmed cases and > 1000
deaths in China.
Lack of critical care resource in face of COVID-19 epidemics
Based on data reported by the National Health Commission of China, there have been
about 2000 new confirmed cases and > 4000 suspected cases daily over the past week
in Wuhan [3]. About 15% of the patients have developed severe pneumonia, and about
6% need noninvasive or invasive ventilatory support. Currently, there are about 1000
patients who need ventilatory support and another 120 new patients daily who require
noninvasive or invasive ventilation support in Wuhan city; however, there are only
about 600 ICU beds [4]. To address this shortfall, 70 ICU beds were created from general
beds and the government quickly transformed three general hospitals to critical care
hospitals with a total of about 2500 beds that specialize in patients with severe
SARS-CoV-2 pneumonia (equipped with monitors and high-flow nasal cannula, noninvasive
ventilator or invasive ventilators).
An equally great (or potentially greater) problem is the shortage of trained personnel
to treat these critically ill patients. Until the crisis, there were about 300 ICU
physicians and 1000 ICU nurses in Wuhan city. By the end of January, more than 600
additional ICU doctors and 1500 ICU nurses were transferred to Wuhan from the rest
of China. As well, an additional 3000 staff including infectious disease, respiratory,
internal medicine physicians and nurses were transferred to Wuhan by the government.
There are logistical issues which make care of the patients difficult. These include
donning of personal protective equipment (e.g., gloves, gowns, respiratory and eye
protection), lack of instruments and disposables, and shortages of supplemental oxygen.
Many severe hypoxemic patients only receive high-flow nasal oxygen (HFNO) or noninvasive
mechanical ventilation rather than invasive mechanical ventilation because of intubation
delay or lack of mechanical ventilators (especially at early phase). Our preliminary data
show that only about 25% of patients who died were intubated and received mechanical
ventilation.
Recommendations
It’s not possible at this stage to create new equipment or personnel. However, it
would be very helpful to have mathematical models developed which predict the expected
number of patients, and the necessary resources (equipment and personnel) required
to treat these patients. This would aid in determining what resources might be moved
to Wuhan to help local health care personnel.
Challenge of early recognition and treatment of critical SARI patients
Several previous reports have described the characteristics of SARS-CoV-2 infected
patients [2, 5, 6]. Most patients are > 50 years of age; the mean age is much older
than patients infected with H1N1 or with Middle East respiratory syndrome (MERS) [7–9].
About 30 to 50% of COVID-19 patients have chronic comorbidities. The duration from
the initial symptom to respiratory failure in most patients is > 7 days, which is
longer than H1N1 [7, 8]. Additionally, many patients that go on to develop respiratory
failure had hypoxemia but without signs of respiratory distress, especially in the
elderly patients (“silent hypoxemia”). Moreover, only a very small proportion of patients
have other organ dysfunction (e.g., shock, acute kidney injury) prior to developing
respiratory failure. These characteristics suggest that traditional methods such as
quick sequential organ failure assessment (qSOFA) score and the new early warning
score (NEWS) may not help predict those patients who will go on to develop respiratory
failure. Therefore, it is urgent to establish a prediction or early recognition model
of patients likely to fail.
Although the novel coronavirus was quickly isolated and sequenced [10], there are
no proven, effective drugs to treat COVID-19. Based on in vitro screening studies,
several drugs were found to inhibit the virus [11]. One case report demonstrated a
surprising effect of remdesivir for SARS-CoV-2 infection [12]; however, the clinical
impact remains unclear. Encouragingly, several clinical trials are undergoing (ChiCTR2000029308,
NCT04252664 and NCT04257656) to determine the effect of lopinavir/ritonavir or remdesivir.
We have also tried Traditional Chinese Medicine such as Xuebijing, and several clinical
trials are ongoing in this regard.
Recommendations
Identifying a biomarker(s) that predicts severity and outcome in COVID-19 patients
early in the presentation would be extremely helpful. Our data (unpublished) demonstrate
that severe lymphopenia and high levels of C-reactive protein correlated with the
severity of hypoxemia and predicted hospital mortality. In addition, the change of
lymphocyte counts during the first 4 days after hospital admission was highly associated
with mortality.
Crisis in management of SARI in the ICU
The mortality rate of SARI is highest (4%) in Wuhan city, followed by other cities
in Hubei province (1.4%) and other provinces (0.25%) [3]. The higher morality in Wuhan
may due to the limited resources, but we are uncertain whether patients are sicker
in Wuhan than in other cities. Understanding the characteristics of the dead patients
would help in triaging patients and allocating resources. We analyzed data of 135
patients who died before Jan 30, 2019, in Wuhan city. Older age and male were common
in non-surviving patients. More than 70% patients had one or more comorbidities. Hypertension
(48.2%) was the most common comorbidity in non-surviving patients, followed by diabetes
(26.7%) and ischemic heart disease (17.0%), similar to data reported by others [5,
6].
Importantly, as stated above, of the patients who died only ~ 25% received invasive
mechanical ventilation or ECMO. The median duration of HFNO and/or NIV was 6(4–8)
days before intubation or death. The mortality of patients who received ECMO is high:
of 28 patients who received ECMO up to the present, 14 died, 5 weaned successfully,
and 9 are still on ECMO. Lack of ventilators, fear of becoming infected during the
intubation procedure, and unclear need for intubation were the main reasons for delaying
invasive ventilation.
Compliance with lung protective ventilation strategy is also low in some centers,
with some patients receiving tidal volumes > 8 ml/kg PBW and with high driving pressures.
Sedation and paralysis strategies are also not standardized. Lack of intensivists
may be a potential cause. Fortunately, we found a significant benefit of prone position
in most severe ARDS patients.
Recommendations
There should be a focus on high-risk patients, e.g., male, > 60 years old, and patients
with comorbidities. Additionally, a standard protocol for SARS-CoV-2 infection recommended
by World Health Organization should be widely implemented [13]. It is crucial that
our staff is trained to employ standard protocols for management, which may help implement
evidence-based ventilatory and general ICU care in the face of an overwhelming workload.
More importantly, in the context of a multidisciplinary team, intensivists should
act as leaders, ensuring that severe patients receive standardized treatment (Fig. 1).
Fig. 1
Some recommendations to face the critical care crisis due to the COVID-19 epidemic
In summary, the COVID-19 epidemic has placed a huge burden on the Chinese health care
system. This crisis has dramatically affected the delivery of critical care due to
a lack of resources, lack of prediction models and of course the lack of effective
pharmacotherapies. Front line critical care clinicians desperately require these tools.