Panel 1.

Recommended management of patients admitted to intensive care unit with Coronavirus disease-19.

• Indication for admission is severe respiratory failure due to pneumonia and acute respiratory distress syndrome with or without shock.

• If the patient is not intubated, perform a trial with non-invasive mechanical ventilation* (preferred option) or high-flow nasal cannula (alternative option, if non-invasive mechanical ventilation is not available) (4–6 h). HFN is preferred due to its better tolerance. • If the patient does not respond, intubate the patient by skilled personnel with maximal precautions. • Obtain an endotracheal aspirate for bacterial and fungal stains and culture and for PCR viral detection.

• Use protective mechanical ventilation according to Surviving Sepsis Campaign (SSC) recommendations. • Use prone position if the patient has a PaO2/FiO2 ratio equal or lower than 100 (12 h minimum). • Consider ECMO when refractory hypoxemia despite prone position. • Manage shock according to SSC recommendations.

• In patients with ARDS administer prednisone or methyl prednisolone (SSC, weak recommendation). • In patients with persistent high D-dimer levels (>3,000 U/mL) consider anticoagulation and rule out pulmonary thromboembolism. • Do not withhold antibacterial treatment. • Continue or change anti-COVID-19 treatment according to hospital protocols and published evidence.

^*Non-invasive mechanical ventilation with Helmet commonly used in intensive care units in Italy.