Prashant NasaElie AzoulayAshish K. KhannaRavi JainSachin GuptaYash JaveriDeven JunejaPradeep RangappaKrishnaswamy SundararajanWaleed AlhazzaniMassimo AntonelliYaseen M. ArabiJan BakkerLaurent J. BrochardAdam M. DeaneBin DuSharon EinavAndrés EstebanOgnjen GajicSamuel M. GalvagnoClaude GuérinSamir JaberGopi C. KhilnaniYounsuck KohJean Baptiste LascarrouFlavia R. MachadoManu L.N.G. MalbrainJordi ManceboMichael T. McCurdyBrendan A. McGrathSangeeta MehtaArmand Mekontso-DessapMervyn MerMichael NurokPauline K. ParkPaolo PelosiJohn V. PeterJason PhuaDavid V. PilcherLise PiquilloudPeter SchellongowskiMarcus J. SchultzManu Shankar-HariSuveer SinghMassimiliano SorbelloRavindranath TiruvoipatiAndrew A. UdyTobias WelteSheila N. MyatraNarayana Superspeciality Hospital, GurugramFaculty of Biology, Medicine and HealthUniversité Paris CitéManchester University NHS Foundation TrustUniversité de MontpellierIRCCS San Martino Polyclinic HospitalUniversité de LyonKing Saud bin Abdulaziz University for Health SciencesFondazione Policlinico Universitario Agostino Gemelli IRCCSErasmus MCMcMaster UniversityCentre Hospitalier Universitaire de MontpellierRoyal Adelaide HospitalWake Forest University School of MedicineNational University HospitalPontificia Universidad Católica de ChileCHU de NantesUniversity of OxfordVrije Universiteit BrusselUniversity of Michigan, Ann ArborUniversità degli Studi di GenovaHôpital Henri MondorCentre Hospitalier Universitaire VaudoisShaare Zedek Medical CenterMonash UniversityTata Memorial HospitalHopital Edouard HerriotUniversity of TorontoUniversity of the Witwatersrand, JohannesburgCedars-Sinai Medical CenterUniversidade Federal de São PauloUniversity of Maryland School of MedicineMahidol UniversityHospital Universitari de BellvitgeVagelos College of Physicians and SurgeonsKing's College LondonMedizinische Universität WienPeking Union Medical College HospitalUniversity of Ulsan College of MedicineMayo ClinicGuy's and St Thomas' NHS Foundation TrustRoyal Melbourne HospitalHospital Universitario de GetafeChelsea and Westminster HospitalAmsterdam UMC - University of AmsterdamGandhi Medical CollegeChristian Medical College, VelloreUniversity of MarylandA.O.U. Policlinico-San MarcoRegency Super Speciality HospitalInternational Fluid AcademyGerman Center for Lung ResearchMax Super Speciality HospitalColumbia Asia Referral HospitalPSRI HospitalNMC Speciality Hospital2022-08-042022-08-042021-12-01Critical Care. Vol.25, No.1 (2021)1466609X136485352-s2.0-85103144157https://repository.li.mahidol.ac.th/handle/20.500.14594/77616Background: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). Results: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.Mahidol UniversityMedicineArticleSCOPUS10.1186/s13054-021-03491-y