SIMEU position paper on non-invasive respiratory support in COVID-19 pneumonia

Abstract

The rapid worldwide spread of the Coronavirus disease (COVID-19) crisis has put health systems under pressure to a level never experienced before, putting intensive care units in a position to fail to meet an exponentially growing demand. The main clinical feature of the disease is a progressive arterial hypoxemia which rapidly leads to ARDS which makes the use of intensive care and mechanical ventilation almost inevitable. The difficulty of health systems to guarantee a corresponding supply of resources in intensive care, together with the uncertain results reported in the literature with respect to patients who undergo early conventional ventilation, make the search for alternative methods of oxygenation and ventilation and potentially preventive of the need for tracheal intubation, such as non-invasive respiratory support techniques particularly valuable. In this context, the Emergency Department, located between the area outside the hospital and hospital ward and ICU, assumes the role of a crucial junction, due to the possibility of applying these techniques at a sufficiently early stage and being able to rapidly evaluate their effectiveness. This position paper describes the indications for the use of non-invasive respiratory support techniques in respiratory failure secondary to COVID-19-related pneumonia, formulated by the Non-invasive Ventilation Faculty of the Italian Society of Emergency Medicine (SIMEU) on the base of what is available in the literature and on the authors' direct experience. Rationale, literature, tips & tricks, resources, risks and expected results, and patient interaction will be discussed for each one of the escalating non-invasive respiratory techniques: standard oxygen, HFNCO, CPAP, NIPPV, and awake self-repositioning. The final chapter describes our suggested approach to the failing patient.

Noninvasive ventilation strategies for patients with severe or critical COVID-19: A rapid review of clinical outcomes

“…This could prove to be challenging in some settings, particularly in low and middle income countries or settings that are acutely impacted by pandemic-related surges or supply shortages. Implementation of monitoring practices seen in the existing clinical trials may not be completely generalizable or feasible to clinical settings outside of the ICU where provider-patient ratios are higher 2 .…”

“…No studies specified patient outcomes or source of infection associated with any particular SARS-COV-2 variants of concern. It has been suggested that use of non-invasive ventilation strategies may increase transmission of SARS-COV-2 to healthcare workers, placing them at risk during care and adding strain to the healthcare system when isolation is required 2,26 . Although appropriate personal protective equipment may provide adequate protection for some healthcare workers when NIV strategies are used, existing studies are predominantly from early 2020 there is a lack of comparative studies available on this topic [67][68][69][70][71][72][73][74][75][76][77][78] .…”

“…The I 2 statistic was used to measure heterogeneity among the included trials. Publication bias was not assessed or small studies effects because fewer than 10 studies were included.…”

“…Severe and critical COVID-19 involves acute hypoxemic respiratory failure requiring oxygen and ventilation therapies1. COVID-19 patients may deteriorate quickly and require hospitalization to prevent progressive hypoxemia, leading to acute respiratory failure 2 .…”