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

Nasa, Prashant; Azoulay, Elie; Khanna, Ashish K.; Jain, Ravi; Gupta, Sachin; Javeri, Yash; Juneja, Deven; Rangappa, Pradeep; Sundararajan, Krishnaswamy; Alhazzani, Waleed; Antonelli, Massimo; Arabi, Yaseen M.; Bakker, Jan; Brochard, Laurent J.; Deane, Adam M.; Du, Bin; Einav, Sharon; Esteban, Andrés; Gajic, Ognjen; Galvagno, Samuel M.; Guérin, Claude; Jaber, Samir; Khilnani, Gopi C.; Koh, Younsuck; Lascarrou, Jean-Baptiste; Machado, Flavia R.; Malbrain, Manu L. N. G.; Mancebo, Jordi; McCurdy, Michael T.; McGrath, Brendan A.; Mehta, Sangeeta; Mekontso-Dessap, Armand; Mer, Mervyn; Nurok, Michael; Park, Pauline K.; Pelosi, Paolo; Peter, John V.; Phua, Jason; Pilcher, David V.; Piquilloud, Lise; Schellongowski, Peter; Schultz, Marcus J.; Shankar-Hari, Manu; Singh, Suveer; Sorbello, Massimiliano; Tiruvoipati, Ravindranath; Udy, Andrew A.; Welte, Tobias; Myatra, Sheila N.

BACKGROUND: 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 (χ(2)) 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. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-021-03491-y.