Table 1 Consensus and stability analysis of the clinical statements on the respiratory management of C-ARF

Section-1: Non-invasive respiratory interventions

1. The pathophysiology of C-ARF is similar to that of ARDS

86.5

0

13.5

5 (0)

0.05

2. Based on your experience, awake self-proning may improve oxygenation in patients with C-ARF

91.9

8.1

0

5 (1)

1.0

3. Based on your experience, awake self-proning may prevent the need for invasive mechanical ventilation in patients with C-ARF*

54.0

35.1

10.9

5 (1)

0.71

4. In which of the following clinical scenarios should awake self-proning be initiated in patients with C-ARF?

NA

0.21

Supplemental oxygen required to maintain SpO₂ > 90%

97.8

Moderate-to-severe COVID-19

73

Increased work of breathing (observed subjectively)

45.9

Tachypnea (respiratory rate ≥ 30/min)

37.8

Never

0

5. HFNO can be considered as an alternative strategy for oxygen support before invasive mechanical ventilation

97.3

2.7

0

6 (0)

0.09

6. When do you initiate HFNO in patients with C-ARF?

NA

0.28

Unable to maintain SpO₂ > 90% using high flow oxygen delivery device through a mask

97.3

Increasing oxygen requirement

81.1

Moderate-to-severe COVID-19

73

Tachypnea (respiratory rate ≥ 30/min)

56.8

Increased work of breathing (observed subjectively)

54.1

Never

0

7. Based on your experience, HFNO may avoid the need for tracheal intubation and invasive mechanical ventilation in patients with C-ARF

81.1

18.9

0

5 (0)

0.35

8. NIV can be considered as an alternative strategy for oxygen support before invasive mechanical ventilation*

64.8

18·9

16.3

5 (2)

0.88

9. NIV may be considered in the following clinical scenarios in patients with C-ARF?

NA

0.44

Mixed Respiratory failure (hypercapnia and hypoxemia)

94.6

Increased work of breathing (observed subjectively)

81.1

Unable to maintain SpO₂ more than 90% with high flow oxygen delivery through a mask

67.6

Moderate-to-severe COVID-19

59.5

Tachypnea (respiratory rate ≥ 30/min)

51.4

Unable to maintain Spo2 more than 90% with HFNO

45.9

10. Based on your experience, NIV may avoid the need for tracheal intubation and invasive mechanical ventilation in patients with C-ARF*

64.8

21.6

13.5

5 (1)

0.06

11. The use of systemic corticosteroids could potentially avoid the need for tracheal intubation and invasive mechanical ventilation in C-ARF

86.5

10.8

0.27

12. In which clinical context would you choose to initiate corticosteroids in C-ARF?

NA

0.35

Critical COVID-19

91.9

Oxygen requirement to maintain SpO₂ more than 92%

73

Moderate-to-severe COVID-19

75.7

All patients with C-ARF

37.8

Taking into consideration of inflammatory markers (CRP etc.)

24.3

Never

0

13. Which corticosteroid is your preferred choice in patients with C-ARF?

NA

0.30

Dexamethasone

86.5

Methylprednisolone

16.2

Type of steroid is immaterial

16.2

Hydrocortisone

5.4

14. What daily dose of corticosteroid (equivalent dose of dexamethasone) you prescribe for C-ARF?

NA

0.22

6 mg (equal to 8 mg of dexamethasone phosphate)

91.9

7 mg–20 mg

10.8

 > 20 mg

2.7

Other

0

15. What duration of corticosteroid use would you prefer for patients with C-ARF?

NA

0.81

5–10 days

86.5

Extended duration for more than 10 days depending on the clinical response

13.5

11–14 days

2.7

More than 14 days

2.7

Section-2: Invasive mechanical ventilation

1. Which of the following options may be considered as an appropriate trigger for tracheal intubation in C-ARF?

NA

0.05

Altered mental status

91.9

Hemodynamic instability

81.1

Failure to maintain SpO₂ > 90% with other non-invasive respiratory interventions

81.1

Persistent respiratory distress

78.4

PaO₂/FiO₂ less than 100

67.6

Increased work of breathing (observed subjectively)

62.2

PaO2/FiO2 less than 200

18.9

Tachypnea (respiratory rate ≥ 30/min)

3.8

2. “Lung protective ventilation” should be used for patients with C-ARF on IMV

100

0

0

6 (1)

1.0

3. A low PEEP strategy (≤ 10 cm of H2O) is usually considered during IMV of C-ARF*

29.7

51.4

18.9

4 (1)

0.003

4. How would you select PEEP in a patient of C-ARF on invasive mechanical ventilation with thorax CT scan showing bilateral pulmonary infiltrates, PaO₂/FiO₂ ratio less than 100 mm Hg, plateau pressure 27 cm of H₂O and PEEP of 6 cm of H₂O?*

NA

NA

Obtaining the best static compliance or lowest driving pressure

54.1

Recruitment manoeuvre followed by PEEP set to either optimal SpO₂ or static lung compliance

40.5

Incremental PEEP to target plateau pressure less than 30 cm H₂O

40.5

Using ARDS-net protocol PEEP tables

37.8

Based on pressure–volume curve

29.7

Using esophageal balloon

16.2

Other

8.1

5. NMBA may be considered during early phase of the invasive mechanical ventilation of C-ARF to avoid patient-ventilator dyssynchrony

89.1

8.2

2.7

6 (1)

0·74

6. The invasive mechanical ventilation strategy in C-ARF should be targeted to the following?

NA

0.94

Tidal volume 4–6 ml/kg of predicted body weight

89.2

Plateau pressure ≤ 30 cm of H₂O

89.2

Driving pressure ≤ 15 cm of H₂O

78.4

Oxygenation (PaO₂/FiO₂ ratio)

29.4

Tidal volume 7–8 ml/kg of predicted body weight

10.8

Other

0

Section-3: Refractory hypoxemia

1. The use of RM in patients with refractory hypoxemia in the setting of C-ARF needs to be personalized to the individual patient in view of its potential deleterious effects

89.2

5.4

5.4

5 (1)

0.26

2. Prone position during invasive mechanical ventilation of C-ARF improves oxygenation

97.3

2.7

0

6 (1)

0.09

3. Prone position during invasive mechanical ventilation of C-ARF is effective when done for (duration per session)?

NA

0.25

16–24 h

94.6

12–15 h

16.2

> 24 h

5.4

12–16 h

0

4. Advanced invasive mechanical ventilation (APRV, PRVC, etc.) modes may be beneficial in refractory hypoxemia with C-ARF*

16.3

43.2

40.5

4(2)

0.03

5. The following adjuvant therapies are effective in refractory hypoxemia with C-ARF?*

NA

0.1

None

54.1

Inhaled nitric oxide

45.9

Other

5.4

Nebulized prostacyclin

8.1

6. V-V ECMO may be considered in C-ARF patients on invasive mechanical ventilation?

NA

0.48

Only in patients with refractory hypoxemia, who do not respond to other adjuvant therapies

83.8

Depending on the national/institutional policy and judicious resource allocation decision

62.2

Only in patients who have failed or have a contraindication to prone positioning

45.9

Early in patients with C-ARF without a trial of prone positioning

2.7

Cannot comment

0

Never

0

Section-4: Infection control

1. The following are considered as aerosol-generating procedures (AGPs)?

NA

0.54

Tracheal intubation

100

Tracheostomy

100

Bronchoscopy

100

Tracheal extubation

97.3

Bag and mask ventilation

97.3

Non-invasive ventilation

97.3

Open suctioning (oral or tracheal)

97.3

Nebulization

94.6

High-flow nasal oxygen therapy

81.1

Chest physiotherapy

64.9

Invasive mechanical ventilation

10

2. HFNO produces less aerosols as compared to NIV with face mask*

37.8

54.1

8.1

4 (1)

0.002

3. The following measures may be considered in the ICU to prevent cross-transmission of SARS-CoV-2?

NA

0.66

Closed suction system

100

Airborne infection isolation room

89.2

Video laryngoscopy over conventional laryngoscopy for intubation

86.5

Heat and moisture exchange filters

62.2

Ventilatory circuit modification for NIV /invasive mechanical ventilation

54.1

Increasing outdoor air ventilation rates (opening windows of ICU)

51.4

NIV with helmet

48.6

Subglottic secretion drainage endotracheal tube

32.4

Intubation boxes

35.1

Delaying tracheal extubation up to ten days

2.7

Which personal protective equipment is acceptable for use during an AGP in ICU?*

NA

0.08

Coverall, goggles or face shield, surgical gloves and N95 (FFP 2) mask

64.9

Coverall, surgical gloves, N95 (FFP 2) mask, goggles and face shield

59.5

Coverall, goggles or face shield, surgical gloves and FFP 3 mask

45.9

Coverall, surgical gloves and powered air-purifying respirator (PAPR)

40.5

PAPR and surgical gloves

8.1

Coverall, goggles or face shield, surgical gloves and surgical mask

2.7

N95 and surgical gloves

0

Section-5: Weaning and tracheostomy

1. Which weaning strategy would you prefer for liberation from invasive mechanical ventilation in patients with C-ARF?

NA

0.33

Pressure support ventilation trial for 30 min to 2 h

89.2

Protocolized weaning

27

T-piece trial for 30 min to 2 h

13.5

Automated weaning protocol on mechanical ventilation

8.1

2. Chest physiotherapy could be beneficial in patients with C-ARF*

62.2

32.4

5.4

5 (1)

0.20

3. Early mobilization of patients is beneficial in patients on respiratory support for C-ARF

94.6

5.4

0

5 (1)

0.16

4. Delay in liberation from invasive mechanical ventilation has lower risk of reintubation in patients with C-ARF

2.7

24.3

73

2 (2)

0.38

5. When should tracheostomy be considered to facilitate weaning from invasive mechanical ventilation?

NA

0.80

Same timing as in a non-COVID-19 patient

91.9

Failed tracheal extubation

13.5

Later than you would perform in a non-COVID-19 patient

10.8

Earlier than you would perform in a non-COVID-19 patient

0

Which of the following technique of performing tracheostomy is preferred in patients with C-ARF?

NA

0.42

Percutaneous tracheostomy with or without guidance (ultrasound or bronchoscopic)

89.2

Surgical tracheostomy in the operation theatre

24.9

Surgical tracheostomy at the bed side

16.2

Other

2.7