Algorithm for Non-Invasive Respiratory Support Pathways in COVID-19 Management

A proposed algorithm for deciding at what times during the treatment of COVID-19 patients to initiate, stop, and / or wean with various non-invasive respiratory therapies (NIRTs) was outlined by researchers in an article published in Pulmonology.

Although the data support the use of various NIRTs in the treatment of acute respiratory failure associated with COVID-19, clinicians lacked a complete understanding of the optimal timing to use and discontinue NIRTs, including conventional oxygen therapy (COT), high-flow nasal Therapy cannula (HFNC), continuous positive airway pressure (CPAP) and bi-level positive pressure ventilation (BiPAP). A better understanding of when and how to use these therapies is critical, as recent data from the International Severe Acute Respiratory and Emerging Infections Consortium suggest that 15% of COVID-19 patients in intensive care units are using CPAP or BiPAP and 14% have received HFNC.

The algorithm developed by the researchers was based on a comprehensive review of current findings on the use of NIRTs in COVID-19-related acute respiratory failure. Researchers developed a decision tree with interdependent steps and specific clinical criteria that cover when and how the use of COT, HFNC, CPAP, and BiPAP should be started, escalated, and reassessed.

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The algorithm also provided detailed criteria and decision-making aids for initiating and using NIV and instructions for rotating NIV / HFNC; Intubation criteria according to CPAP and NIV; Instructions for NIV / HFNC after extubation; and criteria for discontinuing HFNC after extubation.

Researchers also looked at the benefits of early NIRT and the benefits of prone positioning as a “time-saving” measure that can potentially improve outcomes in patients with COVID-19-related shortness of breath. Current evidence suggests that self-puffing (i.e., alert patients rolling onto their stomach or side) with COT, HFNC, mask CPAP, or helmet CPAP can be used to increase oxygen delivery.

The authors said the proposed algorithm could aid decision-making among clinicians working on airway intermediate care units and potentially reduce the enrollment of patients with COVID-19 in congested intensive care units.


Winck JC, Scala R. Non-Invasive Airway Support Pathways in Hospitalized Patients with COVID-19: Proposal of an Algorithm. Pulmonology. 2021; 27 (4): 305-312. doi: 10.1016 / j.pulmoe.2020.12.005

This article originally appeared on Pulmonology Advisor

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