Table 2 Recommendations for providing respiratory care to COVID-19 patients

1

Oxygen therapy

5 in vitro [24,25,26,27,28]

3 in vivo [29,30,31]

• Use nasal cannula and place a surgical/procedure mask on the patient's face

• Avoid Venturi mask

• Avoid nonrebreather mask unless it is filtered

2

High-flow nasal cannula

1 in vitro [32]

2 in vivo [15, 31]

• Proper nasal cannula fitting

• Place a surgical/procedure mask over HFNC on the patient's face (Fig. 2)

3

Nebulization

2 in vitro [33, 34]

2 in vivo [22, 35]

• Use metered dosed inhaler with spacer when possible

• Avoid using small volume nebulizer unless it is filtered (Fig. 3a, b)

• Use nebulizer in line with HFNC or via ventilator

4

Lung expansion and airway clearance therapy*

3 in vivo [22, 35, 36]

• If using IPPB, place a filter between circuit and mask or mouthpiece, or on expiratory port

• If possible, avoid cough inducing therapies such as intermittent percussive ventilation and cough assist

• During high-frequency chest wall oscillation therapy, place a surgical/procedure mask on the patient's face

5

Non-invasive ventilation*

2 in vitro [37, 38]

2 in vivo [39, 40]

• Use tight fit oral mask without leaks, consider helmet or total face mask if available

• Avoid using nasal mask

• When using non-heated-wire single-limb circuit, place a filter between the non-vented mask and the expiratory port (Fig. 4a)

• If humidification is required, heated wire single-limb circuit with filter placed at the expiratory port for non-invasive ventilator (Fig. 4b) or heated wire dual-limb circuits with critical care ventilator can be utilized

6

Intubation and Invasive ventilation*

1 in vitro [41]

4 in vivo [22, 39, 42, 43]

• During bag mask ventilation, place a filter between the mask and resuscitation bag (Fig. 5)

• Most experienced provider performs intubation

• Use video-laryngoscope

• Rapid sequence intubation

• Avoid breaking the ventilator circuit

7

Ventilator weaning

• Avoid cool aerosol for tracheostomy patient, instead use HME. If the patient needs frequent suctioning (more than once every hour), place an in-line suction catheter with T-piece connected to cool aerosol or heated humidification, the other end of T-piece connected to a filter (Fig. 6). Additionally, if the patient has cuffless tracheotomy, place a procedure mask on patient’s face

• Avoid using T-piece trials. If needed, use the setup with a filter described above

8

Extubation*

• When removing the endotracheal tube, simultaneously turn off the ventilator

• Avoid disconnecting ETT from the ventilator circuit before extubation to reduce spray of contaminated aerosols

9

Transport

• Place a filter between the artificial airway and the transport ventilator circuit

• Use HME that has filter function (HME-F)

• Consider clamping the ETT before disconnection from ventilator circuit

10

Bronchoscopy assist*

2 in vivo [44, 45]

• For spontaneously breathing patients, place a surgical mask on patient's face (Fig. 7a, b)

• Use NIV mask with examination port for patients on NIV (Fig. 7d)

• Use swivel adapter to insert bronchoscope for intubated patient (Fig. 7c)