Just the Facts: What are the roles of oxygen escalation and noninvasive ventilation in COVID-19?

Abstract

A 37-year-old female presents with cough, fever, dyspnea, and myalgias for five days after recent contact with a family member with confirmed 2019 coronavirus disease . Her vital signs include T 38.3°C, HR 108, BP 118/ 70 mm Hg, RR 26 breaths per minute, and oxygen saturation 67% on room air. She is not in respiratory distress currently and is protecting her airway. Her chest X-ray reveals bilateral airspace opacities. You plan to immediately intervene and address her hypoxia. KEY CLINICAL QUESTIONS How can oxygen therapy be escalated to avoid intubation?Escalation of oxygen therapy includes a stepwise progression of devices meant to improve oxygenation and reduce patient work of breathing. 1-3 While this escalation may vary based on institution and local infection prevention policies, the basic strategy includes the following:

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation

“…However, many patients can be safely and appropriately managed with non-invasive means of oxygenation and ventilation (i.e., interventions other than endotracheal intubation). For patients with hypoxemia, supplemental oxygen via a low-flow system such as nasal cannula can be used initially [ 7 , 29 ]. If oxygen flow rates greater than 6 L/min via nasal cannula are needed to maintain an oxygen saturation ≥ 90–92%, supplementation via a facemask can be utilized for higher flow rates, or a Venturi mask can be utilized [ [6] , [7] , [8] , 29 ].…”

“…For patients with hypoxemia, supplemental oxygen via a low-flow system such as nasal cannula can be used initially [ 7 , 29 ]. If oxygen flow rates greater than 6 L/min via nasal cannula are needed to maintain an oxygen saturation ≥ 90–92%, supplementation via a facemask can be utilized for higher flow rates, or a Venturi mask can be utilized [ [6] , [7] , [8] , 29 ]. For patients who remain hypoxic or demonstrate increased work of breathing despite these interventions, HFNC or NIPPV can be utilized [ 6 , 7 , 29 ].…”

“…If oxygen flow rates greater than 6 L/min via nasal cannula are needed to maintain an oxygen saturation ≥ 90–92%, supplementation via a facemask can be utilized for higher flow rates, or a Venturi mask can be utilized [ [6] , [7] , [8] , 29 ]. For patients who remain hypoxic or demonstrate increased work of breathing despite these interventions, HFNC or NIPPV can be utilized [ 6 , 7 , 29 ]. With respect to terminology in this review, NIPPV refers to either CPAP or BPAP.…”

Protected 911: Development, Implementation, and Evaluation of a Prehospital COVID-19 High-Risk Response Team

“…The training focused on the pathophysiology of COVID-19, principles of patient management, and the foundations of high-performance teamwork. We adapted our patient care procedures to de-emphasize bag-mask ventilation in favor of an escalating oxygen therapy regimen [ 23 ].…”

Non-invasive respiratory support in the treatment of acute hypoxemic respiratory failure secondary to CoViD-19 related pneumonia

“…Due to the peculiar pathophysiology of this disease, it is important to maintain a gradual administration of respiratory support (oxygen escalation) [30]. However, a retrospective study comparing 373 CoViD-19 patients with a similar group admitted to the same hospitals for viral pneumonia between 2013 and 2017, showed that rapid growth in oxygen requirements itself is highly predictive of the need for positive pressures [31].…”