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

P Nasa, E Azoulay, AK Khanna, R Jain, S Gupta, Y Javeri, D Juneja, P Rangappa, K Sundararajan, W Alhazzani, M Antonelli, Y M Arabi, Hanneke Bakker, LJ Brochard, AM Deane, B Du, S Einav, A Esteban, O Gajic, SM GalvagnoC Guerin, S Jaber, GC Khilnani, Y Koh, JB Lascarrou, FR Machado, M Malbrain, J Mancebo, MT McCurdy, BA McGrath, S Mehta, A Mekontso-Dessap, M Mer, M Nurok, PK Park, P Pelosi, JV Peter, J Phua, DV Pilcher, L Piquilloud, P Schellongowski, MJ Schultz, M Shankar-Hari, S Singh, M Sorbello, R Tiruvoipati, AA Udy, T Welte, SN Myatra

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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 (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.

Original languageEnglish
Article number106
JournalCritical Care
Volume25
Issue number1
DOIs
Publication statusPublished - 16 Mar 2021

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