Respiratory support for adult patients with COVID-19

Jessica S Whittle, Ivan Pavlov, Alfred D Sacchetti, Charles Atwood, Mark S Rosenberg, Jessica S Whittle, Ivan Pavlov, Alfred D Sacchetti, Charles Atwood, Mark S Rosenberg

Abstract

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).

Keywords: BiPAP; COVID‐19; SARS‐CoV‐2; coronavirus; high flow nasal cannula; high flow oxygen; high velocity nasal insufflation; non‐invasive ventilation; viral pneumonia.

Conflict of interest statement

Jessica S. Whittle has served as a consultant to Vapotherm, Inc., within the last 3 years for the development of educational materials. All compensation totaled less than $1000. Ivan Pavlov has been a speaker for Fisher‐Pakyel within the last 3 years. All compensation was paid to the charitable foundation at the hospital where he works and he did not personally receive any compensation. Alfred D. Sacchetti, Charles Atwood, and Mark S. Rosenberg have no disclosures.

© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Figures

FIGURE 1
FIGURE 1
Aerosol dispersion distances (cm) for various oxygen supplementation modalities. Distance depicted is the average dispersal for that modality over the range of flow rates typically used for that modality (NC ranges 3‐40 cm, SM at all flows ≈ 30 cm, VM range 33‐40 cm, NRM at all flows

FIGURE 2

Proposed treatment algorithm for patients…

FIGURE 2

Proposed treatment algorithm for patients with hypoxia due to COVID‐19

FIGURE 2
Proposed treatment algorithm for patients with hypoxia due to COVID‐19
FIGURE 2
FIGURE 2
Proposed treatment algorithm for patients with hypoxia due to COVID‐19

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