Table 4.
Recommendations on use of high flow nasal oxygen (HFNO) and non-invasive ventilation (NIV) in covid-19 from clinical guidelines available early in pandemic
| Guideline | Recommendations |
|---|---|
| World Health Organization9 | High flow nasal oxygen and non-invasive ventilation should be used only in selected patients with hypoxaemic respiratory failure |
| Limited data suggest a high failure rate in patients with other viral infections such as MERS-CoV who receive NIV | |
| Patients receiving a trial of NIV should be in a monitored setting and cared for by experienced personnel capable of endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hour). Patients with haemodynamic instability, multi-organ failure, or abnormal mental status should likely not receive NIV in place of other options such as invasive ventilation | |
| Owing to uncertainty around the potential for aerosolisation, high flow oxygen and NIV, including bubble CPAP, should be used with airborne precautions until further evaluation of the safety can be completed | |
| Ministry of Health, Brazil10 | Consider NIV if mild respiratory distress |
| Proceed with endotracheal intubation if there is no response to NIV using aerosol precautions | |
| National Health Commission, China25 | Timely provision of effective oxygen therapy, including nasal catheter and mask oxygenation, and if necessary, nasal high flow oxygen therapy |
| When respiratory distress and/or hypoxaemia of the patient cannot be alleviated after receipt of standard oxygen therapy, high flow nasal cannula oxygen therapy or NIV can be considered. If conditions do not improve or even get worse within a short time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be used in a timely manner | |
| COREB mission nationale, France11 | In general, techniques at risk of aerosolisation risk contamination of personnel and must be avoided as much as possible (NIV, HFNO) |
| In situations where NIV is still necessary, care givers must wear PPE and the patient must wear a mask. The NIV must be stopped before the mask is removed from the patient. Limit the presence of care givers in the rooms of infected patients receiving treatment with NIV or optiflow (HFNO) | |
| Robert Koch Institute, Germany12 | Early administration of oxygen, possibly non-invasive or invasive ventilation |
| It is important to acknowledge that oxygen supplementation through high flow nasal cannula (HFNC) and NIV leads to aerosol formation. It is therefore absolutely necessary to make sure that HFNC and facemasks are fitted correctly to the patient, and that the medical personnel at the bedside strictly adhere to PPE instructions. NIV with a helmet should be preferred where available | |
| In general, we advise medical professionals to be rather restrictive with HFNC and NIV in the context of covid-19. In patients with severe hypoxemia (PaO2/FiO2 ≤200 mm Hg) we suggest performing early intubation and invasive mechanical ventilation. In any case, continuous monitoring and preparedness for urgent intubation are cornerstones in the treatment of patients with covid-19 with respiratory failure. A delay in intubation in patients failing NIV worsens outcome, and any emergency intubation in this cohort puts medical professionals at risk and should be avoided | |
| Ministry of Health, Holland26 | No specific guidance |
| Ministry of Health and Family Welfare, India14 | The risk of treatment failure is high in patients with MERS treated with NIV, and patients treated with either HFNO or NIV should be closely monitored for clinical deterioration |
| Recent publications suggest that newer HFNO and NIV systems with good interface fitting do not create widespread dispersion of exhaled air and therefore should be associated with low risk of airborne transmission | |
| Ministry of Health, Indonesia13 | The use of NIV is not recommended in pandemic viral disease, because this causes delays in intubation, large tidal volume, and parenchymal injury. The available data, although limited, show the level of failure is high when MERS patients have oxygen therapy with NIV |
| Recent publications show that HFNO and NIV systems use an interface that matches the face so the risk of airborne transmission when patient expires is low | |
| Società Italiana di Malattie Infettive e Tropicali, Italy15 | There is strong evidence that the use of NIV in the treatment of covid-19 pneumonia is associated with a worse outcome. On this basis, WHO recommends, where possible, avoidance of NIV and adoption instead of standards that provide for early intubation. If NIV is used, this must be done within an intensive care unit |
| Japanese Association of Infectious Diseases, Japan16 | No specific guidance |
| Department of Public Health, Malaysia17 | No specific guidance |
| Working group on COVID 2019, Russia18 | It is permissible to use NIV as the beginning of respiratory support in patients with acute respiratory distress |
| With the ineffectiveness of NIV—hypoxaemia, metabolic acidosis or no increase in the PaO2/FiO2 index in 2 hours, high breathing (desynchronisation with a respirator, participation of auxiliary muscles, “failures” during triggering of inspiration on pressure-time curve)—tracheal intubation is indicated | |
| Centre for Disease Control, Saudi Arabia19 | No specific guidance; refers to WHO |
| Central COVID Task Force, South Korea20 | No specific guidance |
| Ministry of Health, Spain21 | HFNO and NIV should be reserved for very specific patients. NIV should under no circumstances delay the indication of intubation. Treatment failure with NIV in MERS was high. Patients with NIV and HFNO should be closely monitored and prepared for possible intubation |
| Center for Disease Control, Taiwan22 | Neither HFNO nor NIV is recommended for routine use in SARS-CoV-2 infected patients |
| According to the treatment experience of MERS patients, the treatment failure rate using NIV is high | |
| Risks associated with NIV include delayed intubation, excessive tidal volume, injurious transpulmonary pressure, and haemodynamic instability | |
| Ministry of Health, Turkey23 | No specific guidance |
| Centers for Disease Control and Prevention, USA24 | No specific guidance |
CPAP=continuous positive airway pressure; MERS-CoV=Middle East respiratory syndrome coronavirus; PPE=personal protective equipment; SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.