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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Nasa, P., Azoulay, E., Khanna, A., Jain, R., Gupta, S., Javeri, Y., Juneja, D., Rangappa, P., Sundararajan, K., Alhazzani, W., Antonelli, M., Arabi, Y., Bakker, J., Brochard, L., Deane, A., Du, B., Einav, S., Esteban, A., Gajic, O., Galvagno, S., Guérin, C., Jaber, S., Khilnani, G., Koh, Y., Lascarrou, J., Machado, F., Malbrain, M., Mancebo, J., McCurdy, M., McGrath, B., Mehta, S., Mekontso-Dessap, A., Mer, M., Nurok, M., Park, P., Pelosi, P., Peter, J., Phua, J., Pilcher, D., Piquilloud, L., Schellongowski, P., Schultz, M., Shankar-Hari, M., Singh, S., Sorbello, M., Tiruvoipati, R., Udy, A., Welte, T. & Myatra, S. 2021, 'Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method', Critical Care, 25(1), article no: 106. https://doi.org/10.1186/s13054-021-03491-y