[48-Year-Old Triathlete with Severe COVID-19 Pneumonia: Successful and Safe Treatment with Oxygen and CPAP]. / 48-jähriger Triathlet mit schwerer COVID-19-Pneumonie: erfolgreiche und sichere Behandlung mit Sauerstoff und CPAP.

We present the case of a 48-year old man, a triathlet, with severe COVID-19 and extensive bilateral pneumonia. On day 7 since onset of symptoms, the patient had fever, cough, rheumatic pain, dyspnea as well as severe hypoxemic respiratory failure (PaO2 49,9 mmHg, PaCO2 35,7 mmHg, Horovitz-Index 130). CT of the lung showed extensive bilateral ground glass opacities.The patient was treated according to a predefined standard, including oxygen supplementation and, after intermittent worsening, with CPAP-ventilation. The patient improved and could be discharged with normal blood gases at ambient air after 12 days of hospitalization. Six weeks after discharge the patient was fully recovered and lung function as well as CT of the lungs were normal.Our case demonstrates that invasive ventilation can successfully be avoided in patients with severe hypoxemia caused by COVID-19 with bilateral pneumonia.

[ECMO Therapy in a Case of Severe ARDS Related to COVID-19]. / ECMO als Therapie des schweren Lungenversagens bei COVID-19.

We report the case of a 60-year old female patient with advanced severe lung injury as a consequence of COVID-19-pneumonia. The patient was initially treated with highflow oxygen via nasal cannula (HFNC) and CPAP for two days but had to be intubated and mechanically ventilated. After failure of mechanical ventilation because of persistant severe hypoxemia treatment was switched to ECMO which was applicated for 24 days. Prognostic parameters indicated a favourable trend after day 14. After discontinuation of ECMO and 11 days of intermittent assisted ventilation via tracheostoma and low dose oxygen (1 l/min), the patient could be transferred to rehabilitation. The last chest radiograph prior to transferral revealed a nearly complete resolution of bilateral pulmonary infiltrates. Our case demonstrates that severe COVID-19-associated lung injury can be reversible even after prolonged ECMO.

ECMO als Therapie des schweren Lungenversagens bei COVID-19

We report the case of a 60-year old female patient with advanced severe lung injury as a consequence of COVID-19-pneumonia. The patient was initially treated with highflow oxygen via nasal cannula (HFNC) and CPAP for two days but had to be intubated and mechanically ventilated. After failure of mechanical ventilation because of persistant severe hypoxemia treatment was switched to ECMO which was applicated for 24 days. Prognostic parameters indicated a favourable trend after day 14. After discontinuation of ECMO and 11 days of intermittent assisted ventilation via tracheostoma and low dose oxygen (1 l/min), the patient could be transferred to rehabilitation. The last chest radiograph prior to transferral revealed a nearly complete resolution of bilateral pulmonary infiltrates. Our case demonstrates that severe COVID-19-associated lung injury can be reversible even after prolonged ECMO.

[Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 - German Respiratory Society]. / Positionspapier zur praktischen Umsetzung der apparativen Differenzialtherapie der akuten respiratorischen Insuffizienz bei COVID-19.

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.