by Prashant Nasa, Elie Azoulay, Ashish K. Khanna, Ravi Jain,
Sachin Gupta, Yash Javeri, Deven Juneja, Pradeep Rangappa, Krishnaswamy
Sundararajan, Waleed Alhazzani, Massimo Antonelli, Yaseen M. Arabi, Jan Bakker,
Laurent J. Brochard, Adam M. Deane, Bin Du…
Critical Care volume 25,
Article number: 106 (2021)
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 (χ2) 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.
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