Knowledge Translation Tools to Guide Care of Non-Intubated Patients With Acute Respiratory Illness During the COVID-19 Pandemic

David Leasa; Paul Cameron; Kimia Honarmand; Tina Mele; Karen J. Bosma

Disclosures

Crit Care. 2021;25(22) 

In This Article

Abstract and Introduction

Abstract

Providing optimal care to patients with acute respiratory illness while preventing hospital transmission of COVID-19 is of paramount importance during the pandemic; the challenge lies in achieving both goals simultaneously. Controversy exists regarding the role of early intubation versus use of non-invasive respiratory support measures to avoid intubation. This review summarizes available evidence and provides a clinical decision algorithm with risk mitigation techniques to guide clinicians in care of the hypoxemic, non-intubated, patient during the COVID-19 pandemic. Although aerosolization of droplets may occur with aerosol-generating medical procedures (AGMP), including high flow nasal oxygen and non-invasive ventilation, the risk of using these AGMP is outweighed by the benefit in carefully selected patients, particularly if care is taken to mitigate risk of viral transmission. Non-invasive support measures should not be denied for conditions where previously proven effective and may be used even while there is suspicion of COVID-19 infection. Patients with de novo acute respiratory illness with suspected/confirmed COVID-19 may also benefit. These techniques may improve oxygenation sufficiently to allow some patients to avoid intubation; however, patients must be carefully monitored for signs of increased work of breathing. Patients showing signs of clinical deterioration or high work of breathing not alleviated by non-invasive support should proceed promptly to intubation and invasive lung protective ventilation strategy. With adherence to these principles, risk of viral spread can be minimized.

Introduction

Preventing hospital transmission of COVID-19 is of utmost importance to avoid "accelerating the curve" during the pandemic. To that end, guidance issued early during the pandemic warned against use of aerosol-generating medical procedures (AGMP), such as non-invasive ventilation (NIV), continuous positive airway pressure (CPAP) and high flow nasal oxygen (HFNO), advocating instead for early intubation in patients with suspected/confirmed COVID-19.[1,2] In early 2020, as hospitals prepared for a surge in patients with COVID-19, this guidance was widely and rapidly adopted, resulting in confusion and some tragic results. In March, 2020, a patient presenting with an acute exacerbation of chronic obstructive pulmonary disease (COPD), who did not want intubation, died in the emergency room of our tertiary care academic centre, when he was denied NIV pending COVID-19 test result. Clearly, the edict against use of non-invasive respiratory support (NRS) was problematic. If all patients presenting to hospital with acute respiratory illnesses (ARI) were to undergo early endotracheal intubation (ETI), ICU capacity would quickly be exceeded. Furthermore, many patients presenting to hospital have common cardiorespiratory diseases for which NIV has proven efficacy, such as COPD and congestive heart failure (CHF) exacerbations, while others have advanced directives limiting life-extending technologies. To deny such patients, NRS options during the pandemic is neither rational nor ethical. Within months, experienced clinicians treating COVID-19 patients made pleas to reconsider the need for early, systematic intubation.[3,4] Conversely, exposing healthcare providers (HCPs) to AGMP in patients potentially infected with the SARS-CoV-2 virus without due caution is reckless. How do we balance the need to care for COVID-19 suspect and positive patients and minimize risk of transmission while still providing evidence-based care to all hospitalized patients with ARI during this pandemic?

Available information on the risk and benefits of AGMP during the COVID-19 pandemic is rapidly evolving, with new observations and empirical data published daily, yet gaps remain between knowledge and practice. Knowledge translation tools are urgently needed to synthesize and transform the best available data into instructions that can be easily implemented by front-line HCPs at the bedside. At our tertiary care academic centre, spanning two hospitals serving a catchment area of 1 million people,[5] we formed a multidisciplinary Ventilation Strategy for COVID-19 Working Group. Our objective, achieved with rapid knowledge translation of emerging literature, was to provide a comprehensive and timely narrative review of this topic and develop recommendations, educational materials and a decision-making algorithm to guide staff managing these patients. The key principles discussed here of mitigating risk of aerosolization, minimizing in-hospital viral transmission, managing acute respiratory failure non-invasively and evading patient self-inflicted lung injury will remain relevant for the next wave of COVID-19, the next influenza season or the next pandemic to come.

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