Nutrition Management of mechanically ventilated patients with COVID-19

The COVID-19 pandemic is a global challenge to people, patients, healthcare professionals, and healthcare systems.

COVID-19 may lead to severe critical illness in patients with comorbidities such as cardiovascular disease, diabetes, cancer, and chronic respiratory disease, specifically in those of advanced age.[i]  

Moreover, severe COVID-19 outcomes manifest as uncontrolled inflammation, the so-called cytokine storm.Topics[ii]^,[iii]^,[iv]

Acute respiratory distress syndrome (ARDS) is a serious complication of COVID-19 and the main cause of mortality.

Patients with ARDS are highly likely to require ventilation support and, consequently, nutritional therapy.Topics[v]

Both the ESPEN COVID-19 guidelinesTopics[vi] as well as the ASPENTopics[vii] endorsed COVID-19 guidelines aim to give practical guidance to health care professionals regarding nutritional therapy of critically ill COVID-19 patients. Regarding the timing, route, dose, and monitoring of nutrition therapy, the recommendations are very similar to those for other ICU patients admitted with pulmonary compromise and requiring ventilation.⁷

When to start PN?

Parenteral nutrition should be initiated if the patient is at nutritional risk and enteral nutrition is insufficient and/or contraindicated.^6,7 It should be started immediately for malnourished patientsTopics[viii] or those at high-risk7 if oral or enteral nutrition is not feasible.

Fig.1: Timing of parenteral nutrition, macronutrients delivery, and nutrition monitoring in critically ill patients with COVID-19. ^6,7,8,9,10 *Propofol: Source of fatty acids: contains 1.1 kcal/ml; CRRT=Continuous Renal Replacement Therapy | ** corresponds to 1.56 g amino acids/kg/d; 100 g parenteral amino acids equivalent to 83 g protein.[xi]

Moreover, COVID-19 patients are at risk of developing gastrointestinal dysfunctions or bowel ischemia. Therefore, the threshold for switching to PN may have to be lower. All these recommendations are fully valid for COVID-19 patients in prone position.⁷ (Fig. 1)

Take advantage of the anti-inflammatory properties of fish-oil

Omega-3 fatty acids from fish oil are direct precursors of potent mediators which play a key role in the resolution of inflammation.[xii] Experts suggest that fish oil containing formulations may help to clear viral infections.⁷

Fish oil-containing PN is associated with statistically and clinically significant positive effects on clinical outcomes, such as lower relative risk of infection and sepsis rates, and shorter length of ICU and hospital stay.[xiii] Thus, omega-3 fatty acids are the only specific nutrients that experts recommend as part of the lipid component in PN admixtures in the ESPEN ICU guidelines.⁸

Be aware of nutritional needs after weaning from mechanical ventilation

After weaning from mechanical ventilation, patients are at risk of swallowing problems at reintroduction of oral intake. This should be assessed in time, with referral to an appropriately trained health care professional if necessary.⁶

Patients are also at high risk of inadequate energy, protein, and fluid intakes and therefore it is essential to monitor oral intake during the convalescence phase.[xiv]

ESPEN recommends textured modified food for patients with dysphagia after extubation. If swallowing is unsafe enteral nutrition should be administered. If a high aspiration risk exists despite post pyloric feeding route, then parenteral nutrition should be considered with removal of nasoenteral tube while the patient receives swallowing training.⁶