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Crit Care
. 2021 Mar 16;25(1):106.
doi: 10.1186/s13054-021-03491-y.
Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method
Prashant Nasa 1 , Elie Azoulay 2 , Ashish K Khanna 3 , Ravi Jain 4 , Sachin Gupta 5 , Yash Javeri 6 , Deven Juneja 7 , Pradeep Rangappa 8 , Krishnaswamy Sundararajan 9 , Waleed Alhazzani 10 , Massimo Antonelli 11 , Yaseen M Arabi 12 , Jan Bakker 13 14 15 , Laurent J Brochard 16 , Adam M Deane 17 , Bin Du 18 , Sharon Einav 19 , Andr?s Esteban 20 , Ognjen Gajic 21 , Samuel M Galvagno Jr 22 , Claude Gu?rin 23 24 , Samir Jaber 25 26 , Gopi C Khilnani 27 , Younsuck Koh 28 , Jean-Baptiste Lascarrou 29 , Flavia R Machado 30 , Manu L N G Malbrain 31 32 , Jordi Mancebo 33 , Michael T McCurdy 34 , Brendan A McGrath 35 36 , Sangeeta Mehta 37 , Armand Mekontso-Dessap 38 , Mervyn Mer 39 , Michael Nurok 40 , Pauline K Park 41 , Paolo Pelosi 42 43 , John V Peter 44 , Jason Phua 45 , David V Pilcher 46 , Lise Piquilloud 47 , Peter Schellongowski 48 , Marcus J Schultz 49 50 51 , Manu Shankar-Hari 52 53 , Suveer Singh 54 , Massimiliano Sorbello 55 , Ravindranath Tiruvoipati 56 , Andrew A Udy 57 , Tobias Welte 58 , Sheila N Myatra 59
Affiliations
- PMID: 33726819
- DOI: 10.1186/s13054-021-03491-y
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 (?2) 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.
Keywords: COVID 19 invasive mechanical ventilation; COVID-19 acute respiratory distress syndrome; COVID-19 high flow nasal oxygen; COVID-19 respiratory management; COVID-19 ventilatory management; Respiratory distress syndrome adult.