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

From: Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

  Agree. (%) Neutral (%) Disagree. (%) Median (IQR) χ2 p-value
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     
  1. Likert scale responses are presented as a percentage of agreement, neutral and disagreement
  2. Options of the multiple-choice type statements are presented in descending order of consensus
  3. Consensus was achieved when there was > 70% agreement/disagreement for the Likert scale and > 80% for multiple-choice type statements
  4. *Clinical statements that did not reach consensus
  5. Median and interquartile range (IQR) were used to describe the central tendency of responses and dispersion along the central value
  6. p value was calculated using χ2: Chi-square. p value was a measure of stability in responses between the two concluding rounds for each statement. p < 0·05 was considered as a significant variation or unstable
  7. Critical COVID-19 is used for ARDS (as per the Berlin definition), sepsis and septic shock (WHO severity definition for COVID-19)24
  8. Agree: agreement; Disagree: disagreement; IQR: interquartile range; C-ARF: COVID-19-related acute respiratory failure; ARDS: acute respiratory distress syndrome; HFNO: high-flow nasal oxygen; NIV: non-invasive ventilation; COVID-19: coronavirus disease 2019; PEEP: positive end expiratory pressure; CT: computed tomography; NMBA: neuromuscular blocking agent; APRV: airway pressure release ventilation; PRVC: pressure-regulated volume control; V–V ECMO: veno–venous extracorporeal membrane oxygenation; AGP: aerosol-generating procedure; ICU: intensive care unit; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; FFP: filtering face piece; PAPR: powered air-purifying respirator.
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Critical Care

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