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 SpO 2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO 2 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 FiO 2 and positive end-expiratory pressure (PEEP) management based on a high FiO 2 /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 (PaO 2 / FiO 2 < 150 mmHg, FiO 2 ³ 0.6 and PEEP ³ 10 cmH 2 O) 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.

Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis

“…Since the early phases of the COVID-19 pandemic, awake prone positioning has been broadly performed worldwide, and it has been recommended by multiple societies, 7 , 8 , 9 because of its potential benefits, low risk, and easy implementation. Furthermore, if it is successfully performed outside of the intensive care unit (ICU), the intervention could spare the very precious resource of ICU bed availability.…”

Rational Use of Oxygen in COVID-19 Pandemic – Are We Doing Enough?

“…19 Another set of recommendations for managing acute respiratory failure in patients with COVID-19 in LMICs suggests maintaining SpO 2 at 88 to 95%. 20 Higher targets for SpO 2 should only be used if continuous monitoring of SpO 2 is not available. 20 There are also several novel suggestions to improve oxygenation in critically ill COVID-19 patients.…”

“…20 Higher targets for SpO 2 should only be used if continuous monitoring of SpO 2 is not available. 20 There are also several novel suggestions to improve oxygenation in critically ill COVID-19 patients. One recent study findings show that putting a surgical mask on top of a high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure.…”

A Call to Action: Reinvigorating Interest and Investments in Health Infrastructure

“…27 However, efforts to scale up oxygen are underway, 28 and the WHO COVID-19 Essential Supplies Forecasting Tool ( https://apps.who.int/iris/rest/bitstreams/1342089/retrieve ) can help to estimate needs for oxygen and other equipment, supplies, and drugs for care and treatment of COVID-19. In addition, recommendations for managing patient oxygen needs in resource-constrained settings are compiled and summarized by Serpa Neto et al 29 …”

“…27 However, efforts to scale up oxygen are underway, 28 and the WHO COVID-19 Essential Supplies Forecasting Tool (https://apps.who.int/ iris/rest/bitstreams/1342089/retrieve) can help to estimate needs for oxygen and other equipment, supplies, and drugs for care and treatment of COVID-19. In addition, recommen-dations for managing patient oxygen needs in resourceconstrained settings are compiled and summarized by Serpa Neto et al 29 For reducing transmission in health care facilities, adequate air filtration and ventilation are paramount 30,31 alongside management of patient flow and personal protective equipment for health care workers. The increased use of intensive care units in the face of COVID-19 further stresses the need for health infrastructure.…”