Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

Abstract

Background Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). Results Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.

Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review

“…Non-invasive respiratory support strategies may fail due to a variety of reasons, including P-SILI itself, high work of breathing, inadequate sedation, decreased level of consciousness, deterioration of gas exchange, interface intolerance, or underlying conditions. 63 A recent consensus of 39 experts 64 concerning the management of COVID-19-related acute respiratory failure using a Delphi method suggested that high-flow nasal oxygen therapy (HFNOT) should be used in patients who are unable to maintain peripheral oxygen saturation (SpO 2 ) > 90% despite oxygen delivery through a Venturi mask, to avoid the need for tracheal intubation and invasive mechanical ventilation. NPPV (with positive end-expiratory pressure, PEEP) should be considered when the patient’s work of breathing increases progressively or in case of mixed (hypoxic and hypercapnic) respiratory failure.…”

The Right Ventricle in COVID-19

“…Indeed, by promoting lung recruitment, prone position reduces hypoxemia, hypercapnia, driving pressure, and plateau pressure, thereby reducing the pulmonary vascular hydraulic load and improving RV function [145]. Most recent guidelines have endorsed prone positioning in the clinical management of severely hypoxemic COVID-19 patients, both under spontaneous awake ventilation (self-proning) and mechanical ventilation [147].…”

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee

“…However, there is insufficient evidence for recommending a specific timing for tracheostomy. 48,49 We recommend leaving the decision on the relative merits of open versus percutaneous tracheostomy to the physician's discretion and institutional experience. 50 -Intubation and tracheostomy should be performed by the most experienced physician to minimize delay or related complications.…”