Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey

Abstract

Background: About 5% of hospitalized coronavirus disease 2019 (COVID-19) patients will need intensive care unit (ICU) admission for hypoxemic respiratory failure requiring oxygen support. The choice between early mechanical ventilation and noninvasive oxygen therapies, such as, high-flow nasal oxygen (HFNO) and/or noninvasive positive-pressure ventilation (NPPV) has to balance the contradictory priorities of protecting healthcare workers by minimizing aerosol-generation and optimizing resource management. This survey over two timeframes aimed to explore the controversial issue of location and noninvasive oxygen therapy in non-intubated ICU patients using a clinical vignette.

Materials and methods: An online survey was designed, piloted, and distributed electronically to Indian intensivists/anesthetists, from private hospitals, government hospitals, and medical college hospitals (the latter two referred to as first-responder hospitals), who are directly responsible for admitting/managing patients in ICU.

Results: Of the 204 responses (125/481 in phase 1 and 79/320 in phase 2), 183 responses were included. Respondents from first-responder hospitals were more willing to manage non-intubated hypoxemic patients in neutral pressure rooms, while respondents from private hospitals preferred negative-pressure rooms (p < 0.001). In both the phases, private hospital doctors were less comfortable to use any form of noninvasive oxygen therapies in neutral-pressure rooms compared to first-responder hospitals (low-flow oxygen therapy: 72 vs 50%, p < 0.01; HFNO: 47 vs 24%, p < 0.01 and NPPV: 38 vs 28%, p = 0.20).

Interpretation: Variations existed in practices among first-responder and private intensivists/anesthetists. The resource optimal private hospital intensivists/anesthetists were less comfortable using noninvasive oxygen therapies in managing COVID-19 patients. This may reflect differential resource availability necessitating resolution at national, state, and local levels.

How to cite this article: Subramaniam A, Haji JY, Kumar P, Ramanathan K, Rajamani A. Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey. Indian J Crit Care Med 2020;24(10):926-931.

Keywords: COVID-19; Conservative oxygen therapy; High-flow nasal cannula oxygen therapy; Hypoxemia; Indian intensive care unit; Low-flow nasal oxygen; NIV: Noninvasive mechanical ventilation; SARS-COV-2.

Figs 1A and B

Proposed location to treat confirmed COVID patients requiring ICU admission: (A) Comfort levels of doctors with different noninvasive oxygenation therapies based on negative pressure room (NPR), neutral pressure room and not an option* for the two phases; (B) Represents distribution based on the type of institution (First-responder** and Private Hospitals) based on phases 1 and 2 refer Supplementary Figure 1 for the statewide distribution and variation among them (presented as actual numbers). *Not an option—implies that there is no role for the type of oxygenation therapy and patients intubated early; **First-responder Hospitals—Government Hospitals and Medical College Hospitals

Figs 2A and B

Oxygenation management preferences: (A) The respondents’ comfort levels for different noninvasive oxygenation therapies based on the type of hospitals they worked; (B) The proportion of respondents’ discomfort logarithmically dropped, more so in phase 2 with the increasing complexity of oxygenation therapies in neutral pressure room in the two phases. NPR, negative pressure room. *First-responder Hospitals—Government Hospitals and Medical College Hospitals

Supplementary Figure 1

The 2 questions in the Survey, discussed in this article.

Supplementary Fig. 2

Variation in comfort levels of intensivists/anesthetists from different states and territories in using noninvasive oxygenation therapies in managing the patient described in the clinical vignette