PMC:7195088 / 35172-39977 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7195088","sourcedb":"PMC","sourceid":"7195088","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7195088","text":"Question 1. how to use at best oxygen therapy and noninvasive mechanical ventilation for preventing intubation?\nIn moderate to severe cases, COVID-19 usually presents as a lung disease (mostly in the form of bilateral interstitial pneumonia) causing hypoxic respiratory failure and requiring passive oxygen therapy. The prevalence of hypoxic respiratory failure in patients with COVID-19 may be as high as 19% [8]. In observational studies conducted in China, 4% to 13% of COVID-19 patients received noninvasive positive pressure ventilation, and 2.3% to 12% required invasive mechanical ventilation [[8], [9], [10]].\nIn general, oxygen treatment should be provided to patients with shortness of breath or hypoxaemia, or those in shock, which is aimed at maintaining an appropriate level of peripheral capillary oxygen saturation (Spo 2), avoiding values of Spo 2 lower than 90% (92–95% in pregnant women). During oxygen supplementation, Spo 2 should not surpass 96% [11].\nAn alternative to conventional oxygen supplementation is supplementation through high-flow nasal cannula (HFNC). HFNC is an oxygen supply system that provides a mixture of air and oxygen with a known concentration. HFNC provides high concentrations of humidified oxygen and low levels of positive end-expiratory pressure; it can also facilitate the elimination of carbon dioxide, thereby potentially reducing the need for intubation compared to standard oxygen supplementation [[12], [13], [14]]. However, it should also be considered that there are no standard evidence-based guidelines for the use of HFNC and that the experience in patients with COVID-19 is still limited (and without adjusted comparison to standard oxygen supplement) to provide universal recommendations, at least pending further data [9]. Other relevant things to be considered are: (a) HFNC should be used in settings with rapid availability of endotracheal intubation in the case of rapid deterioration [15]; and (b) the possible increased risk of contracting the infection for healthcare personnel as a result of aerosol generation should be appropriately managed (HFNC should be used in negative-pressure rooms) [16]. These two considerations also apply to continuous positive airway pressure (CPAP) with helmet (the most frequent system of noninvasive mechanical ventilation used in real life), which can be considered if the patient does not respond to standard or HFNC oxygen supplementation (i.e. if the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao 2/Fio 2) has a decreasing trend) and there is no urgent indication for endotracheal intubation. As for HFNC, also in the case of CPAP with helmet, close monitoring and short interval assessment for worsening of respiratory failure are mandatory. In addition, it should be necessarily noted that although CPAP with helmet has become an established procedure for primary hypoxemic lung failure in the last few years, some experts do not support its use for COVID-19 [15], arguing that success rates in critically ill COVID-19 patients may be limited and there could be a risk of delayed intubation unfavourably influencing the outcome. However, considering the atypical physiopathology of acute lung injury in patients with COVID-19 [17], gentle ventilation with a positive end expiratory pressure (PEEP) not higher than 10 to 12 cm of water may represent a reasonable approach for avoiding excessive damage during CPAP with helmet and possibly also the need for intubation. Large studies, possibly RCT, are urgently needed to definitely clarify the precise role of CPAP with helmet in patients with COVID-19. Finally, borrowing from what is already known and used in intensive care, pronation, although certainly more difficult to implement during noninvasive than invasive mechanical ventilation, may allow improved gas exchange and decreased respiratory distress, and may also promote lung recruitment [18].\n\nQuestion 1 statement\nSupplementary oxygen should be administered to patients with hypoxic respiratory failure for avoiding values of Spo 2 lower than 90%, and it should be aimed at reaching values not higher than 96%. Although still without firm evidence, we currently support the use of CPAP helmet (with gentle ventilation and a PEEP of no more than 10–12 cm of water) if the patient does not respond to standard/HFNC oxygen supplementation and there is no urgent indication for endotracheal intubation (expert opinion). However, no clear indications/criteria can be provided pending further experience. Finally, it should be kept in mind that patients with COVID-19 can get worse in a few hours, so they should be closely monitored for worsening respiratory function so that tracheal intubation and mechanical ventilation can be quickly performed if 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