Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method.
BACKGROUND
Coronavirus 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.


METHODS
Using 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).


RESULTS
Agreement 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.


CONCLUSION
Using 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 REGISTRATION
The study was registered with Clinical trials.gov Identifier: NCT04534569.
['Nasa|Prashant|P|', 'Azoulay|Elie|E|', 'Khanna|Ashish K|AK|', 'Jain|Ravi|R|', 'Gupta|Sachin|S|', 'Javeri|Yash|Y|', 'Juneja|Deven|D|', 'Rangappa|Pradeep|P|', 'Sundararajan|Krishnaswamy|K|', 'Alhazzani|Waleed|W|', 'Antonelli|Massimo|M|', 'Arabi|Yaseen M|YM|', 'Bakker|Jan|J|', 'Brochard|Laurent J|LJ|', 'Deane|Adam M|AM|', 'Du|Bin|B|', 'Einav|Sharon|S|', 'Esteban|Andrés|A|', 'Gajic|Ognjen|O|', 'Galvagno|Samuel M|SM|', 'Guérin|Claude|C|', 'Jaber|Samir|S|', 'Khilnani|Gopi C|GC|', 'Koh|Younsuck|Y|', 'Lascarrou|Jean-Baptiste|JB|', 'Machado|Flavia R|FR|', 'Malbrain|Manu L N G|MLNG|', 'Mancebo|Jordi|J|', 'McCurdy|Michael T|MT|', 'McGrath|Brendan A|BA|', 'Mehta|Sangeeta|S|', 'Mekontso-Dessap|Armand|A|', 'Mer|Mervyn|M|', 'Nurok|Michael|M|', 'Park|Pauline K|PK|', 'Pelosi|Paolo|P|', 'Peter|John V|JV|', 'Phua|Jason|J|', 'Pilcher|David V|DV|', 'Piquilloud|Lise|L|', 'Schellongowski|Peter|P|', 'Schultz|Marcus J|MJ|', 'Shankar-Hari|Manu|M|', 'Singh|Suveer|S|', 'Sorbello|Massimiliano|M|', 'Tiruvoipati|Ravindranath|R|', 'Udy|Andrew A|AA|', 'Welte|Tobias|T|', 'Myatra|Sheila N|SN|0000-0001-6761-163X']
D000086382:COVID-19 D032921:Consensus D003697:Delphi Technique D006801:Humans D012131:Respiratory Insufficiency
COVID 19 invasive mechanical ventilation COVID-19 acute respiratory distress syndrome COVID-19 high flow nasal oxygen COVID-19 respiratory management COVID-19 ventilatory management Respiratory distress syndrome adult