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 GalvagnoClaude 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

Research output: Contribution to journalArticlepeer-review

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
Pages (from-to)106
JournalCritical Care
Volume25
Issue number1
DOIs
Publication statusPublished - 16 Mar 2021

Keywords / Materials (for Non-textual outputs)

  • COVID-19/complications
  • Consensus
  • Delphi Technique
  • Humans
  • Respiratory Insufficiency/therapy

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