Publication: Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- And middle-income countries
Issued Date
2021-03-01
Resource Type
ISSN
14761645
00029637
00029637
Other identifier(s)
2-s2.0-85103251604
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Mahidol University
Rights Holder(s)
SCOPUS
Bibliographic Citation
American Journal of Tropical Medicine and Hygiene. Vol.104, No.3 (2021), 60-71
Suggested Citation
Ary Serpa Neto, William Checkley, Chaisith Sivakorn, Madiha Hashmi, Alfred Papali, Marcus J. Schultz Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- And middle-income countries. American Journal of Tropical Medicine and Hygiene. Vol.104, No.3 (2021), 60-71. doi:10.4269/ajtmh.20-0796 Retrieved from: https://repository.li.mahidol.ac.th/handle/20.500.14594/77313
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Title
Pragmatic recommendations for the management of acute respiratory failure and mechanical ventilation in patients with COVID-19 in low- And middle-income countries
Other Contributor(s)
Faculty of Tropical Medicine, Mahidol University
University of Melbourne
Monash University
Hospital Israelita Albert Einstein
Mahidol University
Nuffield Department of Medicine
Amsterdam UMC - University of Amsterdam
Johns Hopkins School of Medicine
Division of Pulmonary and Critical Care Medicine
Ziauddin Medical College
University of Melbourne
Monash University
Hospital Israelita Albert Einstein
Mahidol University
Nuffield Department of Medicine
Amsterdam UMC - University of Amsterdam
Johns Hopkins School of Medicine
Division of Pulmonary and Critical Care Medicine
Ziauddin Medical College
Abstract
Management of patients with severe or critical COVID-19 is mainly modeled after care for patients with severe pneumonia or acute respiratory distress syndrome (ARDS) from other causes, and these recommendations are based on evidence that often originates from investigations in resource-rich intensive care units located in high-income countries. Often, it is impractical to apply these recommendations to resource-restricted settings, particularly in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for acute respiratory failure and mechanical ventilation management in patients with severe/critical COVID-19 in LMICs. We suggest starting supplementary oxygen when SpO2 is persistently lower than 94%. We recommend supplemental oxygen to keep SpO2 at 88–95% and suggest higher targets in settings where continuous pulse oximetry is not available but intermittent pulse oximetry is. We suggest a trial of awake prone positioning in patients who remain hypoxemic; however, this requires close monitoring, and clear failure and escalation criteria. In places with an adequate number and trained staff, the strategy seems safe. We recommend to intubate based on signs of respiratory distress more than on refractory hypoxemia alone, and we recommend close monitoring for respiratory worsening and early intubation if worsening occurs. We recommend low–tidal volume ventilation combined with FiO2 and positive end-expiratory pressure (PEEP) management based on a high FiO2/low PEEP table. We recommend against using routine recruitment maneuvers, unless as a rescue therapy in refractory hypoxemia, and we recommend using prone positioning for 12–16 hours in case of refractory hypoxemia (PaO2/ FiO2 < 150 mmHg, FiO23 0.6 and PEEP 3 10 cmH2O) in intubated patients as standard in ARDS patients. We also recommend against sharing one ventilator for multiple patients. We recommend daily assessments for readiness for weaning by a low-level pressure support and recommend against using a T-piece trial because of aerosolization risk.