Complications of critical COVID-19: Diagnostic and therapeutic considerations for the mechanically ventilated patient

Maslove, David M.; Sibley, Stephanie; Boyd, J. Gordon; Goligher, Ewan C.; Munshi, Laveena; Bogoch, Isaac I.; Rochwerg, Bram

Patients admitted to the intensive care unit with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated COVID-19 patient who shows persistent or worsening signs of critical illness, and we offer an approach to managing this complex but common scenario.