Respiratory support in patients with COVID-19 (outside intensive care unit). A position paper of the Respiratory Support and Chronic Care Group of the French Society of Respiratory Diseases

Abstract

With first cases noted towards the end of 2019 in China, COVID-19 infection was rapidly become a devastating pandemic. Even if most patients present with a mild to moderate form of the disease, the estimated prevalence of COVID-19-related severe acute respiratory failure (ARF) is 15-20% and 2-12% needed intubation and mechanical ventilation. In addition to mechanical ventilation some other techniques of respiratory support could be used in some forms of COVID-19 related ARF. This position paper of the Respiratory Support and Chronic Care Group of the French Society of Respiratory Diseases is intended to help respiratory clinicians involved in care of COVID-19 pandemic in the rational use of non-invasive techniques such as oxygen therapy, CPAP, non-invasive ventilation and high flow oxygen therapy in managing patients outside intensive care unit (ICU). The aims are: (1) to focus both on the place of each * Corresponding author.

Protective Recommendations for Non-invasive Ventilation During COVID-19 Pandemic: A Bench Evaluation of the Effects of Instrumental Dead Space on Alveolar Ventilation

“… 15 , 16 , 17 Most guidelines recommend NIV in patients with SARS-CoV-2 infection as a “default” option when oxygen therapy or constant positive airway pressure (CPAP) are not sufficient to improve patient's status, provided that appropriate personal protective equipment is available. 10 , 14 , 18 , 19 Its indications in this context therefore remain restricted to situations in which access to invasive mechanical ventilation is limited, in patients not eligible to ICU admission, or in patients with underlying respiratory disease or previously undergoing long-term NIV in which NIV cessation could worsen even more their condition and for whom the results of the present study apply as well. 14 , 20 …”

“… 10 , 14 , 18 , 19 Its indications in this context therefore remain restricted to situations in which access to invasive mechanical ventilation is limited, in patients not eligible to ICU admission, or in patients with underlying respiratory disease or previously undergoing long-term NIV in which NIV cessation could worsen even more their condition and for whom the results of the present study apply as well. 14 , 20 …”

“…This is particularly relevant in patients chronically ventilated pursuing their therapy at home, or exhibiting acute-on-chronic exacerbation requiring hospital admission. 7 , 10 , 14 Of note, even the change from configuration A–E which is often made when patient's condition requires switching to a life-support ventilator needed setting adjustments.…”

Particle generation during positive airway pressure therapy

“…Concerns have been raised that PAP use is an aerosol generating procedure at this time, per CDC 5 . It is reported that non-invasive ventilation is considered an aerosol generating procedure which could increase risk of pathogen exposure and infection and has been recommended for non-vented masks to be used if available 6 . Recently, PAP machine performance was tested and completely sealed systems resulted in worse maximal inspiratory pressures, inspiratory effort to trigger the machine, tidal volume, and work of breathing 7 .…”

High O2 Flow Rates Required to Achieve Acceptable FiO2 in CPAP-Treated Patients With Severe Covid-19: A Clinically Based Bench Study

“… Normal with by-pass leak using a T-connector as recommended to reduce the risk of droplet aerosolization. 6 …”