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.


This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Cite as

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

Downloadable citations

Download HTML citationHTML Download BIB citationBIB Download RIS citationRIS
Last updated: 16 June 2022
Was this page helpful?