Pragmatic Recommendations for the Management of Acute Respiratory Failure and Mechanical Ventilation in Patients with COVID-19 in Low- and Middle-Income Countries

Abstract

Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88-95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low-tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12-16 hours in case of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6 and PEEP ≥ 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.

Conflict of interest statement

GROUP MEMBERS OF THE “COVID-LMIC TASK FORCE”

Heads: Alfred Papali (Atrium Health, Charlotte, NC) and Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, Location “AMC,” Amsterdam, The Netherlands).

Advisors: Neill K. J. Adhikari (Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada); Emilie J. Calvello Hynes (University of Colorado School of Medicine, Department of Emergency Medicine, Denver, CO); Martin Dünser (Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria) and Mervyn Mer (University of the Witwatersrand, Johannesburg, South Africa).

Subgroup members, in alphabetical order: Andrew Achilleos (Sunnybrook Health Sciences Centre, Toronto, Canada); Hanan Y. Ahmed (Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia); Kevan M. Akrami (Universidade Federal da Bahia, Faculdade de Medicina, Salvador, Brazil and Division of Infectious Disease, Department of Medicine, University of California San Diego, San Diego, CA); Lia M. Barros (University of Washington, Seattle, WA); B. Jason Brotherton (AIC Kijabe Hospital, Kijabe, Kenya); Sopheakmoniroth Chea (Calmette Hospital, Phnom Penh, Cambodia); William Checkley (The Johns Hopkins University School of Medicine and The Johns Hopkins University Center for Global Health, Baltimore, MD); Elif A. Cizmeci (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Natalie Cobb (University of Washington, Seattle, WA); Finot Debebe (Department of Emergency Medicine and Critical Care, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia); Juliana Ferreira (University of São Paulo, São Paulo, Brasil); Gabriela Galli (University of Pittsburgh School of Medicine, Pittsburgh, PA); Tewodros Haile (Department of Internal Medicine, College of Health Sciences, Addis Ababa University); Bhakti Hansoti (Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD); Madiha Hashmi (Ziauddin University, Karachi, Pakistan); Rebecca Inglis (Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit [LOMWRU], Mahosot Hospital, Vientiane, Lao People’s Democratic Republic and Department of Intensive Care, Oxford University Hospital Trust, Oxford, United Kingdom); Burton W. Lee (Critical Care Department, NIH, Bethesda, MD; Division of Pulmonary, Allergy and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA); Faith Lelei (AIC Kijabe Hospital, Kijabe, Kenya); Ganbold Lundeg (Mongolian National University of Medical Sciences, Ulan Bator, Mongolia); David Misango (The Aga Khan University, Nairobi, Kenya); Ary Serpa Neto (Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia; Department of Intensive Care, Amsterdam University Medical Centers, Location “AMC,” University of Amsterdam, Amsterdam, The Netherlands); Alfred Papali (Atrium Health, Charlotte, NC); Casey Park (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); Rajyabardhan Pattnaik (Ispat General Hospital, Rourkela, India); Jennifer L. Pigoga (Division of Emergency Medicine, University of South Africa, Cape Town, South Africa); Luigi Pisani (Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Doctors with Africa – CUAMM, Padova, Italy; Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand); Elisabeth D. Riviello (Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA); Kristina E. Rudd (University of Pittsburgh School of Medicine, Pittsburgh, PA); Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, Location “AMC,” Amsterdam, The Netherlands); Varun U. Shetty (University of Pittsburgh Medical Center, Pittsburgh, PA); Gentle S. Shrestha (Tribhuvan University Teaching Hospital, Kathmandu, Nepal); Chaisith Sivakorn (Mahidol University, Salaya, Thailand); Shaurya Taran (Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada); T. Eoin West (University of Washington, Seattle, WA).

Group members of the subgroup “Acute Respiratory Failure and Mechanical Ventilation”: Ary Serpa Neto (Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia; Department of Intensive Care, Amsterdam University Medical Centers, Location “‘AMC,” University of Amsterdam, Amsterdam, The Netherlands), Marcus Schultz (Mahidol University, Bangkok, Thailand; University of Oxford, Oxford, United Kingdom; Amsterdam University Medical Centers, Location “AMC’ ”Amsterdam, The Netherlands), William Checkley (The Johns Hopkins University School of Medicine and The Johns Hopkins University Center for Global Health, Baltimore, MD), Chaisith Sivakorn (Mahidol University, Salaya, Thailand), Madiha Hashmi (Ziauddin University, Karachi, Pakistan), and Alfred Papali (Atrium Health, Charlotte, NC).

Figures

Figure 1.

Oxygen delivery interfaces with HFNO and NIV in COVID-19 patients. (A) Placement of a surgical mask over the HFNO interface may reduce exhaled air dispersion. (B and C) Example of single limb NIV circuit setup with a non-vented mask and viral filter. HFNO = high-flow nasal oxygen; NIV = noninvasive ventilation. Source: Produced by Chaisith Sivakorn, thanks to Napid Wadmanee, respiratory nurse at the Hospital for Tropical Diseases, Bangkok, Thailand, for the graphical input; permission is granted for the reuse of this figure.