• 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 Galvagno, Claude Guérin, Samir Jaber, Gopi C Khilnani, Younsuck Koh, LascarrouJean-BaptisteJBNantes University Hospital, Nantes, France., Flavia R Machado, MalbrainManu L N GMLNGInternational Fluid Academy, Lovenjoel, Belgium.Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium., 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, and Sheila N Myatra.
• Critical Care Medicine, NMC Speciality Hospital, Dubai, United Arab Emirates.
• Crit Care. 2021 Mar 16; 25 (1): 106106.

BackgroundCoronavirus 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.MethodsUsing 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).ResultsAgreement 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.ConclusionUsing 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 RegistrationThe study was registered with Clinical trials.gov Identifier: NCT04534569.

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