High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure

Abstract

The coronavirus disease 2019 pandemic will be remembered for the rapidity with which it spread, the morbidity and mortality associated with it, and the paucity of evidence-based management guidelines. One of the major concerns of hospitals was to limit spread of infection to health-care workers. Because the virus is spread mainly by respiratory droplets and aerosolized particles, procedures that may potentially disperse viral particles, the so-called “aerosol-generating procedures” were avoided whenever possible. Included in this category were noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and awake (nonintubated) proning. Accordingly, at many health-care facilities, patients who had increasing oxygen requirements were emergently intubated and mechanically ventilated to avoid exposure to aerosol-generating procedures. With experience, physicians realized that mortality of invasively ventilated patients was high and it was not easy to extubate many of these patients. This raised the concern that HFNC and NIV were being underutilized to avoid intubation and to facilitate extubation. In this article, we attempt to separate fact from fiction and perception from reality pertaining to the aerosol dispersion with NIV, HFNC, and awake proning. We describe precautions that hospitals and health-care providers must take to mitigate risks with these devices. Finally, we take a practical approach in describing how we use the three techniques, including the common indications, contraindications, and practical aspects of application.

COVID‐19‐related disease severity in pregnancy

“…Limited data on prone positioning in nonpregnant patients suggest that the prone position might be beneficial for treatment of respiratory distress and improves outcomes. 74,75 This approach has been described in pregnant patients infected with COVID-19. Pregnancy presents some additional challenges regarding positioning in the third trimester with a gravid abdomen; however, with appropriate support positioning has been safely accomplished.…”

Oxygen therapy via high flow nasal cannula in severe respiratory failure caused by Sars-Cov-2 infection: a real-life observational study

“…The rationale of this approach is that failure rate of noninvasive ventilatory techniques in COVID-19 patients is high, and these AGP place caregivers at increased risk of contracting COVID-19 infection. 24 …”

“…It has been described that aerosol-mitigating interventions, such as the use of high-energy particulate accumulator (HEPA) filters, negative–pressure rooms and full PPE, are sufficient to protect medical and nursing staff. 24 Several studies have examined aerosol dispersion during use of various AGP, and the results regarding HFNC have been reassuring. When compared with other AGP, HFNC are characterised by a shorter air dispersion distance.…”

“… 36 If negative-pressure rooms are not available, as in our case, rooms with natural ventilation characterised by airflow of at least 160 l/s per patient are recommended. 24 …”

Non-invasive ventilation in patients with novel coronavirus infection COVID-19

“…В отделениях медицинских учреждений, не оборудованных комнатами с отрицательным давлением, вероятно более сильное рассеяние и загрязнение выдыхаемого воздуха. Если помещения с отрицательным давлением недоступны, рекомендуется использовать естественную вентиляцию с потоком воздуха ≥ 160 л / с на 1 пациента, а также фильтр-аккумулятор высокой энергии (HEPA) [35].…”