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

From: Practical strategies to reduce nosocomial transmission to healthcare professionals providing respiratory care to patients with COVID-19

  Respiratory intervention Evidence resource Recommendation
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)
  1. Abbreviations: HFNC high-flow nasal cannula, IPPB intermittent positive pressure breathing, HME heat moisture exchanger, ETT endotracheal tube, NIV non-invasive ventilation
  2. *Based on CDC guidelines, these procedures should ideally be performed in airborne infection isolation rooms