Critical Care (Mar 2021)

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

  • 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,
  • Sharon Einav,
  • Andrés Esteban,
  • Ognjen Gajic,
  • Samuel M. Galvagno,
  • Claude Guérin,
  • Samir Jaber,
  • Gopi C. Khilnani,
  • Younsuck Koh,
  • Jean-Baptiste Lascarrou,
  • Flavia R. Machado,
  • Manu L. N. G. Malbrain,
  • Jordi Mancebo,
  • Michael T. McCurdy,
  • Brendan A. McGrath,
  • Sangeeta Mehta,
  • Armand Mekontso-Dessap,
  • Mervyn Mer,
  • Michael Nurok,
  • Pauline K. Park,
  • Paolo Pelosi,
  • John V. Peter,
  • Jason Phua,
  • David V. Pilcher,
  • Lise Piquilloud,
  • Peter Schellongowski,
  • Marcus J. Schultz,
  • Manu Shankar-Hari,
  • Suveer Singh,
  • Massimiliano Sorbello,
  • Ravindranath Tiruvoipati,
  • Andrew A. Udy,
  • Tobias Welte,
  • Sheila N. Myatra

DOI
https://doi.org/10.1186/s13054-021-03491-y
Journal volume & issue
Vol. 25, no. 1
pp. 1 – 17

Abstract

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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 (χ 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.

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