Introduction
Methods
Delphi process
Agreement and stability
Expert clinical practice statements
Results
Agree. (%) | Neutral (%) | Disagree. (%) | Median (IQR) | χ2 p-value | |
---|---|---|---|---|---|
Section-1: Non-invasive respiratory interventions | |||||
1. The pathophysiology of C-ARF is similar to that of ARDS | 86.5 | 0 | 13.5 | 5 (0) | 0.05 |
2. Based on your experience, awake self-proning may improve oxygenation in patients with C-ARF | 91.9 | 8.1 | 0 | 5 (1) | 1.0 |
3. Based on your experience, awake self-proning may prevent the need for invasive mechanical ventilation in patients with C-ARF* | 54.0 | 35.1 | 10.9 | 5 (1) | 0.71 |
4. In which of the following clinical scenarios should awake self-proning be initiated in patients with C-ARF? | NA | 0.21 | |||
Supplemental oxygen required to maintain SpO2 > 90% | 97.8 | ||||
Moderate-to-severe COVID-19 | 73 | ||||
Increased work of breathing (observed subjectively) | 45.9 | ||||
Tachypnea (respiratory rate ≥ 30/min) | 37.8 | ||||
Never | 0 | ||||
5. HFNO can be considered as an alternative strategy for oxygen support before invasive mechanical ventilation | 97.3 | 2.7 | 0 | 6 (0) | 0.09 |
6. When do you initiate HFNO in patients with C-ARF? | NA | 0.28 | |||
Unable to maintain SpO2 > 90% using high flow oxygen delivery device through a mask | 97.3 | ||||
Increasing oxygen requirement | 81.1 | ||||
Moderate-to-severe COVID-19 | 73 | ||||
Tachypnea (respiratory rate ≥ 30/min) | 56.8 | ||||
Increased work of breathing (observed subjectively) | 54.1 | ||||
Never | 0 | ||||
7. Based on your experience, HFNO may avoid the need for tracheal intubation and invasive mechanical ventilation in patients with C-ARF | 81.1 | 18.9 | 0 | 5 (0) | 0.35 |
8. NIV can be considered as an alternative strategy for oxygen support before invasive mechanical ventilation* | 64.8 | 18·9 | 16.3 | 5 (2) | 0.88 |
9. NIV may be considered in the following clinical scenarios in patients with C-ARF? | NA | 0.44 | |||
Mixed Respiratory failure (hypercapnia and hypoxemia) | 94.6 | ||||
Increased work of breathing (observed subjectively) | 81.1 | ||||
Unable to maintain SpO2 more than 90% with high flow oxygen delivery through a mask | 67.6 | ||||
Moderate-to-severe COVID-19 | 59.5 | ||||
Tachypnea (respiratory rate ≥ 30/min) | 51.4 | ||||
Unable to maintain Spo2 more than 90% with HFNO | 45.9 | ||||
10. Based on your experience, NIV may avoid the need for tracheal intubation and invasive mechanical ventilation in patients with C-ARF* | 64.8 | 21.6 | 13.5 | 5 (1) | 0.06 |
11. The use of systemic corticosteroids could potentially avoid the need for tracheal intubation and invasive mechanical ventilation in C-ARF | 86.5 | 10.8 | 0.27 | ||
12. In which clinical context would you choose to initiate corticosteroids in C-ARF? | NA | 0.35 | |||
Critical COVID-19 | 91.9 | ||||
Oxygen requirement to maintain SpO2 more than 92% | 73 | ||||
Moderate-to-severe COVID-19 | 75.7 | ||||
All patients with C-ARF | 37.8 | ||||
Taking into consideration of inflammatory markers (CRP etc.) | 24.3 | ||||
Never | 0 | ||||
13. Which corticosteroid is your preferred choice in patients with C-ARF? | NA | 0.30 | |||
Dexamethasone | 86.5 | ||||
Methylprednisolone | 16.2 | ||||
Type of steroid is immaterial | 16.2 | ||||
Hydrocortisone | 5.4 | ||||
14. What daily dose of corticosteroid (equivalent dose of dexamethasone) you prescribe for C-ARF? | NA | 0.22 | |||
6 mg (equal to 8 mg of dexamethasone phosphate) | 91.9 | ||||
7 mg–20 mg | 10.8 | ||||
> 20 mg | 2.7 | ||||
Other | 0 | ||||
15. What duration of corticosteroid use would you prefer for patients with C-ARF? | NA | 0.81 | |||
5–10 days | 86.5 | ||||
Extended duration for more than 10 days depending on the clinical response | 13.5 | ||||
11–14 days | 2.7 | ||||
More than 14 days | 2.7 | ||||
Section-2: Invasive mechanical ventilation | |||||
1. Which of the following options may be considered as an appropriate trigger for tracheal intubation in C-ARF? | NA | 0.05 | |||
Altered mental status | 91.9 | ||||
Hemodynamic instability | 81.1 | ||||
Failure to maintain SpO2 > 90% with other non-invasive respiratory interventions | 81.1 | ||||
Persistent respiratory distress | 78.4 | ||||
PaO2/FiO2 less than 100 | 67.6 | ||||
Increased work of breathing (observed subjectively) | 62.2 | ||||
PaO2/FiO2 less than 200 | 18.9 | ||||
Tachypnea (respiratory rate ≥ 30/min) | 3.8 | ||||
2. “Lung protective ventilation” should be used for patients with C-ARF on IMV | 100 | 0 | 0 | 6 (1) | 1.0 |
3. A low PEEP strategy (≤ 10 cm of H2O) is usually considered during IMV of C-ARF* | 29.7 | 51.4 | 18.9 | 4 (1) | 0.003 |
4. How would you select PEEP in a patient of C-ARF on invasive mechanical ventilation with thorax CT scan showing bilateral pulmonary infiltrates, PaO2/FiO2 ratio less than 100 mm Hg, plateau pressure 27 cm of H2O and PEEP of 6 cm of H2O?* | NA | NA | |||
Obtaining the best static compliance or lowest driving pressure | 54.1 | ||||
Recruitment manoeuvre followed by PEEP set to either optimal SpO2 or static lung compliance | 40.5 | ||||
Incremental PEEP to target plateau pressure less than 30 cm H2O | 40.5 | ||||
Using ARDS-net protocol PEEP tables | 37.8 | ||||
Based on pressure–volume curve | 29.7 | ||||
Using esophageal balloon | 16.2 | ||||
Other | 8.1 | ||||
5. NMBA may be considered during early phase of the invasive mechanical ventilation of C-ARF to avoid patient-ventilator dyssynchrony | 89.1 | 8.2 | 2.7 | 6 (1) | 0·74 |
6. The invasive mechanical ventilation strategy in C-ARF should be targeted to the following? | NA | 0.94 | |||
Tidal volume 4–6 ml/kg of predicted body weight | 89.2 | ||||
Plateau pressure ≤ 30 cm of H2O | 89.2 | ||||
Driving pressure ≤ 15 cm of H2O | 78.4 | ||||
Oxygenation (PaO2/FiO2 ratio) | 29.4 | ||||
Tidal volume 7–8 ml/kg of predicted body weight | 10.8 | ||||
Other | 0 | ||||
Section-3: Refractory hypoxemia | |||||
1. The use of RM in patients with refractory hypoxemia in the setting of C-ARF needs to be personalized to the individual patient in view of its potential deleterious effects | 89.2 | 5.4 | 5.4 | 5 (1) | 0.26 |
2. Prone position during invasive mechanical ventilation of C-ARF improves oxygenation | 97.3 | 2.7 | 0 | 6 (1) | 0.09 |
3. Prone position during invasive mechanical ventilation of C-ARF is effective when done for (duration per session)? | NA | 0.25 | |||
16–24 h | 94.6 | ||||
12–15 h | 16.2 | ||||
> 24 h | 5.4 | ||||
12–16 h | 0 | ||||
4. Advanced invasive mechanical ventilation (APRV, PRVC, etc.) modes may be beneficial in refractory hypoxemia with C-ARF* | 16.3 | 43.2 | 40.5 | 4(2) | 0.03 |
5. The following adjuvant therapies are effective in refractory hypoxemia with C-ARF?* | NA | 0.1 | |||
None | 54.1 | ||||
Inhaled nitric oxide | 45.9 | ||||
Other | 5.4 | ||||
Nebulized prostacyclin | 8.1 | ||||
6. V-V ECMO may be considered in C-ARF patients on invasive mechanical ventilation? | NA | 0.48 | |||
Only in patients with refractory hypoxemia, who do not respond to other adjuvant therapies | 83.8 | ||||
Depending on the national/institutional policy and judicious resource allocation decision | 62.2 | ||||
Only in patients who have failed or have a contraindication to prone positioning | 45.9 | ||||
Early in patients with C-ARF without a trial of prone positioning | 2.7 | ||||
Cannot comment | 0 | ||||
Never | 0 | ||||
Section-4: Infection control | |||||
1. The following are considered as aerosol-generating procedures (AGPs)? | NA | 0.54 | |||
Tracheal intubation | 100 | ||||
Tracheostomy | 100 | ||||
Bronchoscopy | 100 | ||||
Tracheal extubation | 97.3 | ||||
Bag and mask ventilation | 97.3 | ||||
Non-invasive ventilation | 97.3 | ||||
Open suctioning (oral or tracheal) | 97.3 | ||||
Nebulization | 94.6 | ||||
High-flow nasal oxygen therapy | 81.1 | ||||
Chest physiotherapy | 64.9 | ||||
Invasive mechanical ventilation | 10 | ||||
2. HFNO produces less aerosols as compared to NIV with face mask* | 37.8 | 54.1 | 8.1 | 4 (1) | 0.002 |
3. The following measures may be considered in the ICU to prevent cross-transmission of SARS-CoV-2? | NA | 0.66 | |||
Closed suction system | 100 | ||||
Airborne infection isolation room | 89.2 | ||||
Video laryngoscopy over conventional laryngoscopy for intubation | 86.5 | ||||
Heat and moisture exchange filters | 62.2 | ||||
Ventilatory circuit modification for NIV /invasive mechanical ventilation | 54.1 | ||||
Increasing outdoor air ventilation rates (opening windows of ICU) | 51.4 | ||||
NIV with helmet | 48.6 | ||||
Subglottic secretion drainage endotracheal tube | 32.4 | ||||
Intubation boxes | 35.1 | ||||
Delaying tracheal extubation up to ten days | 2.7 | ||||
Which personal protective equipment is acceptable for use during an AGP in ICU?* | NA | 0.08 | |||
Coverall, goggles or face shield, surgical gloves and N95 (FFP 2) mask | 64.9 | ||||
Coverall, surgical gloves, N95 (FFP 2) mask, goggles and face shield | 59.5 | ||||
Coverall, goggles or face shield, surgical gloves and FFP 3 mask | 45.9 | ||||
Coverall, surgical gloves and powered air-purifying respirator (PAPR) | 40.5 | ||||
PAPR and surgical gloves | 8.1 | ||||
Coverall, goggles or face shield, surgical gloves and surgical mask | 2.7 | ||||
N95 and surgical gloves | 0 | ||||
Section-5: Weaning and tracheostomy | |||||
1. Which weaning strategy would you prefer for liberation from invasive mechanical ventilation in patients with C-ARF? | NA | 0.33 | |||
Pressure support ventilation trial for 30 min to 2 h | 89.2 | ||||
Protocolized weaning | 27 | ||||
T-piece trial for 30 min to 2 h | 13.5 | ||||
Automated weaning protocol on mechanical ventilation | 8.1 | ||||
2. Chest physiotherapy could be beneficial in patients with C-ARF* | 62.2 | 32.4 | 5.4 | 5 (1) | 0.20 |
3. Early mobilization of patients is beneficial in patients on respiratory support for C-ARF | 94.6 | 5.4 | 0 | 5 (1) | 0.16 |
4. Delay in liberation from invasive mechanical ventilation has lower risk of reintubation in patients with C-ARF | 2.7 | 24.3 | 73 | 2 (2) | 0.38 |
5. When should tracheostomy be considered to facilitate weaning from invasive mechanical ventilation? | NA | 0.80 | |||
Same timing as in a non-COVID-19 patient | 91.9 | ||||
Failed tracheal extubation | 13.5 | ||||
Later than you would perform in a non-COVID-19 patient | 10.8 | ||||
Earlier than you would perform in a non-COVID-19 patient | 0 | ||||
Which of the following technique of performing tracheostomy is preferred in patients with C-ARF? | NA | 0.42 | |||
Percutaneous tracheostomy with or without guidance (ultrasound or bronchoscopic) | 89.2 | ||||
Surgical tracheostomy in the operation theatre | 24.9 | ||||
Surgical tracheostomy at the bed side | 16.2 | ||||
Other | 2.7 |
Expert clinical practice statements
Is COVID-19-related ARDS similar to other forms of ARDS?
Expert statement
Discussion
Corticosteroids
Expert statement
Discussion
Awake self-proning
Expert statement
Discussion
High Flow Nasal Oxygen (HFNO)
Expert statement
Discussion
Non-invasive ventilation and continuous positive airway pressure (CPAP)
Expert statement
Discussion
Tracheal intubation
Expert statement
Discussion
Lung protective ventilation
Expert statement
Discussion
Recruitment manoeuvres
Expert statement
Discussion
Neuromuscular blocking agents (NMBA)
Expert statement
Discussion
Prone ventilation
Expert statement
Veno-Venous extracorporeal membrane oxygenation (V-V ECMO)
Expert statement
Discussion
Infection control
Expert statement
Discussion
Weaning from invasive mechanical ventilation
Expert statement
Discussion
Early mobilisation
Expert statement
Discussion
Tracheostomy
Expert statement
Discussion
Dissensus among the experts on the respiratory management of C-ARF
Strengths and limitations
Pathophysiology | Exploration of “personalised” respiratory interventions based on phenotypes (using clinical, physiological, biological or radiological criteria) |
Awake self-proning | Optimal technique (such as complete prone or side to side), timing and duration Impact on escalation of respiratory support, tracheal intubation and mortality Effect of combination with HFNO or NIV on outcome measures |
HFNO | Risk of aerosolisation, optimal setting, monitoring and prediction of failure Comparison with NIV/CPAP and weaning strategies Use in moderate-to-severe hypoxemia (PaO2/FiO2 less than 200 mm Hg) Impact on outcomes (ICU/hospital length of stay and mortality) |
NIV (including CPAP) | Risk of aerosolisation, monitoring, helmet versus other interfaces Multimodal strategies with HFNO Impact on escalation of respiratory support, outcomes (ICU/hospital length of stay and mortality) Impact of NIV in subset of patients with mixed respiratory failure, cardiogenic pulmonary oedema and COVID-19-related ARDS |
Corticosteroids | Effect of timing of initiation, different types, dose, optimal duration, tapering schedule Impact of laboratory biomarkers on timing, dose and duration of corticosteroid Interaction of corticosteroids with other COVID-19 therapeutics such as Remdesivir, Baricitinib, etc |
Invasive mechanical ventilation | Initiation of invasive mechanical ventilation: Optimal timing, triggers and technique with respect to patient and HCW safety Impact of non-conventional ventilation strategies based on respiratory mechanics on outcomes (ICU/hospital length of stay and mortality) Sedation and NMBA: Optimal sedation strategy and monitoring techniques. Timing, duration, technique (continuous versus bolus) and monitoring of NMBA PEEP: Strategy for personalisation and method of selection Fluid management: Restrictive versus liberal. Impact on ARDS phenotypes Assessing fluid responsiveness Weaning and liberation: Optimal timing and strategy. Impact of HFNO or NIV post-extubation. Predictive measures for failure ECMO: Optimal timing and patient selection. Resource planning in the constraints of a pandemic |
Tracheostomy | Optimal timing, strategy for HCWs safety and post-procedure care. Direct effect of SARS-CoV-2 virus on larynx and trachea |
Infection control | Strategy for HCWs safety during aerosol generating procedures in resource limited settings Role of different types of PPE and strategies to optimize their use De-escalation of isolation precautions: time and/or testing based Impact of different interventional strategies on the reduction in aerosolisation Efficacy and safety of tele-ICU or remote monitoring to limit exposure |