Non-invasive Respiratory Support in COVID-19: A Narrative Review

Abstract

Acute respiratory failure secondary to COVID-19 pneumonia may require a variety of non-pharmacological strategies in addition to oxygen therapy to avoid endotracheal intubation. The response to all these strategies, which include high nasal flow, continuous positive pressure, non-invasive ventilation, or even prone positioning in awake patients, can be highly variable depending on the predominant phenotypic involvement. Deciding when to replace conventional oxygen therapy with non-invasive respiratory support, which to choose, the role of combined methods, definitions, and attitudes toward treatment failure, and improved case improvement procedures are directly relevant clinical questions for the daily care of critically ill COVID-19 patients. The experience accumulated after more than a year of the pandemic should lead to developing recommendations that give answers to all these questions.

Prone Position and the Risk of Venous Thrombosis in COVID-19 Patients with Respiratory Failure

“…Moreover, due to such increased risk of developing venous thrombosis, it may be advisable to refrain from maintaining prone positioning in the so-called “nonresponders” (i.e., in those with ARDS but without significant respiratory improvement after pronation) immediately after the initial pronation sessions. 12…”

Lessons from COVID-19 in the management of acute respiratory failure

“…A stepwise increase from a first-line HFT approach to a step up to positive pressure therapy in cases with a lack of response has been proposed. This may have the pitfall of rescuing very few patients, as most of those who fail HFT will also fail in a positive pressure trial and may need intubation after all [ 91 ]. Thus, it has been considered an inappropriate strategy by expert group recommendations [ 92 ], suggesting that HFT failure may prompt direct intubation.…”

Biological effects of COVID-19 on lung cancer: Can we drive our decisions

“…Accordingly, as initial respiratory support, the primary treatment choices include oxygen therapy, high-flow nasal cannula, and noninvasive ventilation. If these methods fail, mechanical ventilation becomes mandatory for improving lung ventilation, which is compromised upon infection with SARS-CoV-2 ( 58 ). One of the main strategies that has been adopted in the ICU to promote oxygenation is that the patients are maintained in the prone position, which also improves the functional residual capacity and ventilation/perfusion.…”

“…One of the main strategies that has been adopted in the ICU to promote oxygenation is that the patients are maintained in the prone position, which also improves the functional residual capacity and ventilation/perfusion. This approach is also used in awake patients, although the associated principles have not been fully defined ( 58 , 59 ).…”