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Unit V Promoting Health in Patients With Oxygenation Disorders
Treatment Currently there is no cure for COVID-19 disease. Treat- ments are mainly supportive and directed toward prevent- ing severe illness, hospitalization, and death. Management of patients with mild symptoms not requiring hospital- ization is aimed toward reducing symptoms and rein- forcement of public health measures for mitigating viral spread. Hospitalization is indicated for patients with severe COVID-19 illness indicated by signs and symptoms sug- gestive of hypoxia, respiratory distress, and poor perfusion such as dyspnea at rest, feeling breathless with minimal activity, inability to speak in full sentences, peripheral and/or central cyanosis, peripheral oxygen saturation less than 92% on room air, chest pain, and altered mental status. It is important to be on high alert for impending respiratory failure, which can happen rapidly early in the hospital course. The National Institutes of Health (NIH) suggests titrating oxygen to a saturation goal between 92% and 96% for most patients (NIH, 2022). Studies have demonstrated that oxygen saturations below 92% and above 96% are associated with poorer outcomes and increased morbidity. For patients with underlying chronic respiratory conditions (e.g., chronic obstructive pulmonary disease [COPD], obstructive sleep apnea), a target oxygen saturation of 88% to 92% is acceptable. The poorer out- comes for patients with an oxygen saturation greater than 96% suggest more conservative oxygenation goals may be favorable in COVID-19. Additionally, it is important to be aware of the potential for hyperoxic-induced lung injury with prolonged delivery of higher FiO2 concentrations. Target oxygenation goals are still under investigation. Oxygen delivery systems utilized for COVID-19 patients are limited in the effort to minimize aerosolization of the virus, which can place healthcare workers at risk. The use of overlying surgical masks to limit aerosolization is suggested but effectiveness has not been established. See Chapter 7 for discussion of noninvasive oxygen delivery methods. The decision to utilize specific oxygen methods is best made by an interprofessional team, including respiratory therapists, based on an understanding of the benefits and drawbacks for each therapy. Continuous monitoring of responses to oxygen therapy is critical to ensure optimum support at the least harmful level. In the setting of severe COVID-19 with respiratory compromise, it is imperative to not delay intubation when indicated by the presence of any one or more of the follow- ing signs and symptoms: respiratory rate greater than 30, accessory muscle use, SpO 2 less than 92% on maximum noninvasive support, Glasgow Coma Scale score less than 8, PaO 2 /FiO 2 ratio less than 100 mm Hg, arterial pH less than 7.25, and increasing serum lactate levels. Intubation should be performed by experienced providers utilizing video laryngoscopy (when available) to maximize distance from the patient’s open airway and minimize aero- solization. Pre-oxygenation is accomplished using high-flow nasal cannula plus nonrebreathing mask for at least 5 minutes in place of bag-valve mask. After successful intubation of the
airway, placement confirmation is initially done using end- tidal CO 2 detector followed by a chest x-ray. For patients in the intensive care unit, mechanical ventilation management for COVID-19 patients closely follows those established by the Acute Respiratory Distress Syndrome Network (ARDSNet) trial that utilizes a lung protective strategy of lower delivered lung volumes under higher pressures. Post-intubation sedation is essential for patients to maintain ventilator synchrony and receive max- imum benefit from the therapy. Some patients will require higher doses of sedation and possibly the addition of neu- romuscular blockade (chemical paralysis) to avoid ventila- tor desynchrony (see discussion of ARDS in Chapter 27). Medications Vaccination for SARS-CoV-2 is considered the best pre- ventive strategy to curtail the pandemic. Current evidence from vaccine trials (mRNA, adenoviral vector) indicates a sufficient neutralizing response to the SARS-CoV-2 virus, and vaccination is widely supported as the best strategy for preventing and avoiding severe COVID-19 illness, hospi- talization, and death. Infection or reinfection after recov- ery and/or vaccination remains poorly understood. Despite the quickened pace of vaccine development, safety standards have remained strict throughout the research and administration process. The first emergency use authorization (EUA) vaccines were made available in December 2020, initially recommended for high-risk individuals (hospital staff, front-line/essential workers, age over 65 years, and long-term care residents) as a preven- tive public health measure. The availability of vaccination for the general public was approved by the U.S. Food and Drug Administration (FDA) as of February 2022. Outpatient symptom management consists of antipyretics, analgesics, and adequate fluid intake and rest to reduce fevers, relieve myalgias, and avoid dehydration. Outpatients with moderate illness and who are at risk for progression to severe illness may receive antiviral medications listed in Table 24.6. Connection Check 24.2 The nurse should question which of the following orders for a COVID-19 patient’s care? A. Humidified oxygen via nasal cannula B. Lovenox 30 mg bid C. Vital signs every 4 hours D. Continuous pulse oximetry Medications used for the inpatient treatment of COVID-19 patients have shown benefits of limiting the production of viral cells, decreasing the duration of illness, lessening complications, and reducing mortality (Table 24.7). High rates of coagulopathy have also been described in patients with COVID-19 and manifest as acute pulmonary embolism, myocardial infarction, deep vein thrombosis, and arterial thrombosis. Hypercoagulability results from the stasis of blood flow, hyperviscosity of blood,
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