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


Crit Care. 2021;25(22) 

In This Article

Defining the Risk of Hospital Transmission Versus the Risk of Early Intubation

The novel coronavirus SARS-CoV-2 has infected over 50 million people worldwide to date;[7] based on data from China, Europe and the USA, approximately 20% of those infected require hospitalization, and 3–7% require support for acute respiratory failure.[8–12] Recent data show that between 9 and 17% of COVID-19 cases are infected HCPs.[13–15] In northern Italy, 11.4% of HCPs working in respiratory units with patients undergoing AGMP tested positive for COVID-19 during a 2.5-month observation period.[12] The risk to HCP is not negligible; thus, their safety is paramount in the management of ARI throughout the pandemic.

Transmission of the SARS-CoV-2 virus is primarily through droplet spread.[10] These droplets (particles > 5–10 μm in diameter) are affected by gravity and may cause direct transmission from close contact or contribute to contamination of surfaces within 1.5–2.0 m, where the virus may remain active for hours to days.[16,17] However, some events can generate aerosols composed of smaller virus-containing particles (< 5–10 μm) suspended in air. Until further data become available, it should be assumed that NRS measures are potentially AGMP. Dispersion distances for various treatment modalities have been described using human patient simulator technology to mimic different devices and severity of lung disease (Table 1).[18–22] However, with careful attention to risk mitigation strategies, the maximum exhaled air distance may be reduced compared to conventional oxygen therapy (Table 1).

Avoidance of NRS in patients with suspected/confirmed COVID-19 in favour of early endotracheal intubation (ETI) as first-line therapy carries risk of morbidity to patients, including immobilization, disuse diaphragmatic atrophy, ventilator-associated infections, and potential for long-term physical and neurocognitive dysfunction,[23] with risk of overwhelming ICU and ventilator capacity. Thus, a strategy is required to identify and safely manage patients likely to benefit from NRS while protecting HCP from risk of contagion through AGMP, and to identify those patients likely to require early ETI, protecting them from risk of increased mortality associated with delay of inevitable intubation.[24]