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Review
. 2021 Jan 8;25(1):22.
doi: 10.1186/s13054-020-03415-2.

Knowledge translation tools to guide care of non-intubated patients with acute respiratory illness during the COVID-19 Pandemic

Collaborators, Affiliations
Review

Knowledge translation tools to guide care of non-intubated patients with acute respiratory illness during the COVID-19 Pandemic

David Leasa et al. Crit Care. .

Abstract

Providing optimal care to patients with acute respiratory illness while preventing hospital transmission of COVID-19 is of paramount importance during the pandemic; the challenge lies in achieving both goals simultaneously. Controversy exists regarding the role of early intubation versus use of non-invasive respiratory support measures to avoid intubation. This review summarizes available evidence and provides a clinical decision algorithm with risk mitigation techniques to guide clinicians in care of the hypoxemic, non-intubated, patient during the COVID-19 pandemic. Although aerosolization of droplets may occur with aerosol-generating medical procedures (AGMP), including high flow nasal oxygen and non-invasive ventilation, the risk of using these AGMP is outweighed by the benefit in carefully selected patients, particularly if care is taken to mitigate risk of viral transmission. Non-invasive support measures should not be denied for conditions where previously proven effective and may be used even while there is suspicion of COVID-19 infection. Patients with de novo acute respiratory illness with suspected/confirmed COVID-19 may also benefit. These techniques may improve oxygenation sufficiently to allow some patients to avoid intubation; however, patients must be carefully monitored for signs of increased work of breathing. Patients showing signs of clinical deterioration or high work of breathing not alleviated by non-invasive support should proceed promptly to intubation and invasive lung protective ventilation strategy. With adherence to these principles, risk of viral spread can be minimized.

Keywords: COVID-19; High flow nasal oxygen; Non-invasive ventilation; Prone positioning; ROX index.

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Conflict of interest statement

The authors declare they have no competing interests.

Figures

Fig.1
Fig.1
a Acute respiratory illness (ARI) early management decision algorithm (COVID-19). The ARI decision algorithm guides determination of the level of support required for the hypoxemic patient, and patient factors that determine appropriateness for NIV, HFNO, awake prone positioning and intubation. b Personal protective equipment, isolation and level of monitoring required for various treatments and conditions during COVID-19. This table accompanies a and outlines the PPE, isolation strategy and level of monitoring required for non-AGMP, AGMP and high-risk AGMP care. ARI acute respiratory illness, RR, respiratory rate, AGMP aerosol generating medical procedure, COPD chronic obstructive pulmonary disease, OSA obstructive sleep apnea, OHS obesity hypoventilation syndrome, NMD neuromuscular disease, CHF congestive heart failure, WOB work of breathing, HFNO high flow nasal oxygen, NIV non-invasive ventilation, Bi-PAP bi-level positive airway pressure, CPAP continuous positive airway pressure. AAMI Association for the Advancement of Medical Instrumentation, PPE personal protective equipment, ICU intensive care unit
Fig. 2
Fig. 2
a Modified ICU NIV. Pictured is the Hamilton C5® ventilator with dual limb circuit but without heated humidifier. Non-vented mask; combined anti-bacterial/viral filter/HME; and flow sensor lines. Filters at inspiratory and expiratory ports. b Modified Hospital NIV. Pictured is the Philips Respironics V60® ventilator with single limb circuit but without heated humidifier. Non-vented mask with anti-asphyxia valve; combined anti-bacterial/viral filter and HME; distal exhalation port; and proximal pressure line. Second filter at inspiratory port. c Modified Home NIV. Pictured is the ResMed Stellar 150® bi-level ventilator with single limb circuit but without heated humidifier. Non-vented mask with anti-asphyxia valve; combined anti-bacterial/viral filter/HME; and distal exhalation port. Second filter at inspiratory port. Oxygen port at rear of device. Insert details the anti-asphyxia valve. NIV non-invasive ventilation, HH heated humidifier, FEP filtered exhalation port, HME heat and moisture exchanger, AAV anti-asphyxia valve; *determined by local practice
Fig. 3
Fig. 3
a Infographic. Techniques to reduce droplet dispersion during HFNO and CPAP. Pictorial representation of techniques to reduce droplet dispersion during aerosol-generating medical procedures. b Infographic. COVID-19 Circuit Modifications for Non-Invasive Ventilation. Pictorial representation of circuit modifications for NIV use during the COVID-19 pandemic

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