Table 4.

Additional respiratory interventions in the ICU.

Intubation and mechanical ventilation	Patients with worsening hypoxia, hypercapnia, acidaemia, respiratory fatigue, haemodynamic instability or those with altered mental status should be considered for early invasive mechanical ventilation if appropriate.12 The risk of aerosol transmission is reduced once a patient is intubated with a closed ventilator circuit.12
Recruitment manoeuvres	Although current evidence does not support the routine use of recruitment manoeuvres in non-COVID-19 ARDS, they could be considered in patients with COVID-19 on a case-by-case basis.12
Prone positioning	Anecdotal reports from international centres dealing with large numbers of critically ill patients with COVID-19-related ARDS suggest that prone ventilation is an effective strategy in mechanically ventilated patients.12 In adult patients with COVID-19 and severe ARDS, prone ventilation for 12 to 16 hours per day is recommended.22,23 It requires sufficient human resources and expertise to be safely performed, to prevent known complications including pressure areas and airway complications.
Bronchoscopy	Bronchoscopy carries a significant risk of aerosol generation and transmission of infection. The clinical yield is thought to be low in COVID-19 and unless there are other indications (such as suspected atypical/opportunistic superinfection or immunosuppression) it is strongly advised to avoid the procedure.12
Suctioning	Closed inline suction catheters are recommended.12
Sputum samples	In a ventilated patient, tracheal aspirate samples for diagnosis of COVID-19 are sufficient and bronchoalveolar lavage is not usually necessary.12 Any disconnection of the patient from the ventilator should be avoided to prevent lung decruitment and aerosolisation. If necessary, the endotracheal tube should be clamped and the ventilator disabled (to prevent aerosolisation).12
Tracheostomy	Tracheostomy could be considered in suitable patients to facilitate nursing care and expedite ventilator weaning, but is an aerosolising procedure and this must be considered in clinical decision making.12

ARDS = acute respiratory distress syndrome, COVID-19 = coronavirus disease 2019, ICU = intensive care unit.