Expert Consensus Statements for the Management of COVID-19-Related Acute Respiratory Failure Using a Delphi Method

Prashant Nasa; Elie Azoulay; Ashish K. Khanna; Ravi Jain; Sachin Gupta; Yash Javeri; Deven Juneja; Pradeep Rangappa; Krishnaswamy Sundararajan; Waleed Alhazzani; Massimo Antonelli; Yaseen M. Arabi; Jan Bakker; Laurent J. Brochard; Adam M. Deane; Bin Du; Sharon Einav; Andrés Esteban; Ognjen Gajic; Samuel M. Galvagno Jr.; Claude Guérin; Samir Jaber; Gopi C. Khilnani; Younsuck Koh; Jean-Baptiste Lascarrou; Flavia R. Machado; Manu L. N. G. Malbrain; Jordi Mancebo; Michael T. McCurdy; Brendan A. McGrath; Sangeeta Mehta; Armand Mekontso-Dessap; Mervyn Mer; Michael Nurok; Pauline K. Park; Paolo Pelosi; John V. Peter; Jason Phua; David V. Pilcher; Lise Piquilloud; Peter Schellongowski; Marcus J. Schultz; Manu Shankar-Hari; Suveer Singh; Massimiliano Sorbello; Ravindranath Tiruvoipati; Andrew A. Udy; Tobias Welte; Sheila N. Myatra


Crit Care. 2021;25(106) 

In This Article

Abstract and Introduction


Background: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

Methods: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ 2) test (p < 0·05 was considered as unstable).

Results: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

Conclusion: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

Trial registration: The study was registered with Clinical Identifier: NCT04534569.


Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as a pandemic, resulting in unprecedented pressure on healthcare systems globally. Although most patients present with mild symptoms including fever and malaise, 8–32% of patients presenting to hospital may require admission to the intensive care unit (ICU),[1–3] depending on the admission criteria and available resources, with an ICU mortality of 34–50%.[3,4]

Patients with coronavirus disease 2019 (COVID-19) acute respiratory failure (C-ARF) who are admitted to the ICU with hypoxaemia typically require some form of respiratory support.[5] COVID-19-related acute respiratory distress syndrome (ARDS) may differ from other causes of ARDS, since patients may present with profound hypoxaemia accompanied by a wide range of respiratory compliance.[6–8] However, whether ARDS due to COVID-19 is clinically similar to other forms of ARDS remains a matter of debate.[7,9–11] Consequently, there is no uniform agreement on the optimal management of respiratory failure, including the most appropriate oxygenation and ventilation strategies that limit or prevent additional lung injury or other complications in these patients.

There are few published randomised controlled trials (RCTs) related to the respiratory management of C-ARF. As a result, clinical practice variations in the management of C-ARF exist, making the optimal therapeutic management unclear.[12] Given the dearth of evidence, we aimed to achieve agreement on the respiratory management of C-ARF using a Delphi process, defined by at least 70% agreement among experts who met pre-specified qualification criteria.