1

RECOMMENDATIONS FOR THE USE OF NON-INVASIVE

MECHANICAL VENTILATION, NON-MECHANICAL CPAP SYSTEMS AND

HIGH FLOW NASAL OXYGEN THERAPY IN PATIENTS WITH

COVID-19 RESPIRATORY INFECTION

SPANISH MULTIDISCIPLINARY GROUP OF EXPERTS IN NON-INVASIVE RESPIRATORY THERAPIES

NIV-RC GROUP

Dr. José Miguel Alonso Íñigo. Consultant. Department of Anaesthesia, Critical Care and Pain Medicine. Hospital Universitario y Politécnico La Fe. Valencia (Spain). Director NIV-CV Group Dr. José Manuel Carratalá Perales.Consultant. Department of Emergency Medicine. Hospital Gereral Universitario de Alicante (Spain). Co-Director NIV-CR Group Dr. Salvador Diaz Lobato. Consultant in Pneumology. Medical Director Nippon Gases. Co-Director VMNI-CR Group

RespiratoryCare

Valencia

Non InvasiveVentilation

NIVRC

ValenciaGroup

NIV-RCGroup Spain

2

INTRODUCTION The NIV-CR Group aims to define the recommendations for the use of non-invasive therapies (NIT) for respiratory support in patients with respiratory infection due to COVID-19 (RICOVID-19) and acute respiratory failure (ARF). The information provided in this document is based on recommendations from experts in Non-Invasive Ventilation (NIV), on the analysis of evidence, and on the protocols, experience and recommendations of centres and physicians who are treating this type of cases. We consider the possibility of including all currently available ventilatory support techniques to be of fundamental importance, given the logistical difficulties in providing ventilators and intensive care beds in many hospital centres. All these in an environment of maximum security for all the health personnel involved in the care of these patients. These recommendations are complementary to the current recommendations and protocols for ventilatory management of patients with IRCOVID-19 and severe ARF. Under no circumstances are they intended to replace these recommendations, and they have been developed in the context of an extremely serious health situation. Our objective is to add and contribute our knowledge and share our experience so that, as far as possible, no patient is left without ventilatory support. The results of a recent selected cohort analysis of 1,099 patients with COVID-19 in China has shown that up to 15% (173/1,099) developed severe disease according to the American Thoracic Society's clinical criteria for severe community pneumonia (1). Of these, 19% were admitted to intensive care units, requiring the use of mechanical ventilation, both invasive and non-invasive, in 46% (81/173) and with a mortality of 8% (14/173). In addition, 2.9% (5/173) was treated with extracorporeal oxygenation systems. A recent publication in a total of 191 hospitalized patients with COVID-19 infection in, shown an incidence of ARDS of 31% with a mortality of 93% (2). Thus, it is clear the importance of applying a phased and appropriate strategy to patients infected with RICOVID-19.

3

GENERAL POINTS • COVID-19 ARI occurs in most cases with HYPOXEMIA, which can be severe in a large

number of cases and develop ARDS • Initial ventilatory support in the most severe cases requires admission to Critical Care

Units, Respiratory Care Units or any other unit of the hospital centre that has the material and human resources to provide adequate care in a safe manner.

• Invasive Mechanical Ventilation (IMV) is the therapy of choice in patients with the following criteria:

Ø Clinical criteria: § Moderate to severe dyspnoea with signs of increase work of breathing

(WOB) and use of accessory muscles or paradoxical abdominal movement § Tachypnoea greater than 30 rpm

Ø Gasometric criteria: § PaO2/FiO2 <200 (or the need to administer FiO2 greater than 0.4 to

achieve SpO2 of at least 92%). § Acute ventilatory failure (pH < 7.35 with PaCO2 > 45 mm Hg).

• The use of non-invasive therapies (NIT) is only recommended as initial treatment in

patients with ARF de novo in selected cases and with staff experienced in treating hypoxemic patients. According to the WHO recommendations, (January 28, 2020 in section 5, and the last update of March 13, 2020 in section 7), both High Flow Nasal Oxygen Therapy (HFNT) and Non-Invasive Mechanical Ventilation (NIV) should only be used in selected patients, considering the possibility of high treatment failure (3,4). Therefore, close monitoring and the possibility of rescuing the patient with invasive mechanical ventilation (IMV) is necessary.

• In the same document and also in other studies it is sown that the adequate use of interfaces and high-flow nasal cannulas during NIT by adequately trained personnel does not increase the dispersion of infectious particles and should therefore not be associated with increased airborne transmission of the disease (5-8).

4

SPECIFIC CONSIDERATIONS • NITs can be an alternative to IMV in cases of COVID-19 ARF in the following situations:

§ As an initiation therapy in selected cases treated by NIT experts and in a safe environment

§ As a bridge therapy to the start of IMV § As the only therapy when an IMV ventilator is not expected to be available § For medical transport of patients § For out-of-hospital ventilatory support in primary care centres or emergency care

centres until arrival or transfer to a hospital § As palliative therapy in selected cases § In the "weaning" phase of the IMV § In patients with “do-not-intubate” orders

• Although there are no clear recommendations for the use of NIT in patients with hypoxemic ARF associated with viral infectious processes in the lungs (SARS, MERS), we believe that an alternative approach to NIT application may provide better management of these patients (9-11).

• In most studies in hypoxemic patients it seems that (HFNT) is a clear alternative to conventional oxygen therapy with a decrease in morbidity (12-15).

• The failure of NIV in the hypoxemic patient has been associated with the use of a high tidal volumes (9 ml/kg), as a consequence of low PEEP/EPAP/CPAP and high-pressure support (PS), increasing the "driving pressure" (16). On the other hand, there is a wide variability in the application of NIV in relation to the type of interfaces, interface rotation protocols, use of active humidification systems, types of ventilators (specific for NIV or not), duration of therapy and ventilatory alternatives to disconnection periods.

• We consider that NIT should be performed in a uniform manner with clear protocols in relation to the characteristics of the patients' ventilatory mechanics and always in an environment of maximum safety for healthcare personnel (17,18).

• The ventilatory strategy of the HIPOXEMIC patient is different from that of the HYPERCAPNIC and requires a different approach.

• NIT in the hypoxemic patient is included in a new concept and therapeutic approach promoted by our group: LUNG PROTECTIVE NIT.

• The NIT ROTATION strategy is an important aspect in the treatment of hypoxemic patients, since it allows a continuation of therapy and a decrease in side effects. A recent study in patients with ARF risk factors after extubation has shown that the combination of therapies (THFNT + NIV / CPAP) was superior to therapies alone (19).

5

MANAGEMENT WITH NIT IN PATIENTS WITH ACUTE RESPIRATORY

INSUFFCIENCY CUASED BY COVID-19

GENERAL TREATMENT GOALS IN HYPOXEMIC PATIENTS WITH NON-INVASIVE THERAPY (NIT)

• Improve PaO2 (PaO2/FiO2 ratio) • Promote alveolar recruitment • Measures to prevent alveolar derecruitment • Establish the optimal PEEP/CPAP/EPAP for each patient • Decrease MV-induced lung damage ("stress-strain") • Decrease WOB) • Decrease diaphragmatic activity and respiratory drive (tachypnoea control) • Avoiding patient-induced lung damage • Avoiding endotracheal intubation

LUNG PROTECTION RECOMMENDATIONS AND OBJECTIVES IN THE

CONTEXT OF NIT • When using NIMV/Non-Mechanical CPAP systems:

§ High levels of CPAP/PEEP/EPAP between 10-14 cmH2O § FiO2 required for SpO2 greater than or equal to 92-93% § If Pressure Support (PS) is needed, assess the Vt to avoid lung overdistension. § Do not use values of PS higher than 5 cmH2O as a general rule § Vt target of 6 ml/kg ideal weight § When non-mechanical CPAP systems are used, clinical evaluation of

overdistension is used to titrate pressure levels. Ask the patient about sensation and comfort at different CPAP levels.

• When using HFNT

§ Choosing the right nasal cannulas appropriate to the size of the nostrils § Therapy with high flows of at least 50 L/min. § Test by increasing the gas flow rate to 80 L/min, ensuring patient’s tolerance. § FiO2 required for an SpO2 greater than or equal to 92-93%.

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• TNI INTERFACE ROTATION strategy (See Appendix) § Hypoxemic patients do not tolerate window periods without NIT, as early

derecruitment and hypoxia can occur. § Alternating NIV/CPAP with HFNT is an appropriate rotation strategy aimed at

maintaining NIT on an ongoing basis while minimizing side effects § Different types of interfaces must be available to establish a rotation strategy § Do not use “vented” masks since they have leak holes in the mask body that act as

expiratory port. § Use masks with blue elbow (standard elbow) or elbows without anti asphyxia valve (see

below) § The first line interfaces in the hypoxemic are: Performax (Philips) or similar "total face"

and Helmet (Intersurgical) since the therapy will be prolonged and are usually better tolerated by patients. The Helmet can be used with both non-mechanical CPAP systems and double-limb ventilators (20).

§ Selecting the high flow nasal cannula size will aim to occlude at least 50% of the nostrils. § In any case, therapy can be started and the interface rotation can be established

according to the patient's needs or the presence of side effects. § It is recommended to evaluate the interface rotation every 6-8 hours. § It is important to know which type of ventilator or ventilatory system is being used for

the choice of the appropriate connecting elbow and the anti-pollution safety measures to be used (see below under ventilatory systems and safety measures)

• Strategy for NIT in prone position

§ NIT with the patient in a prone position may be useful in selected cases. § There are few studies on the effect of the application of NIT with patients in prone with

severe hypoxemia, but it seems that it may be a strategy to consider in early stages and selected patients (21,22).

§ We understand that prone position in patients with NIT may involve an unbearable care burden in certain circumstances and this should be done if safety measures can be maintained for health personnel.

§ In the case of opting for a prone position strategy, the recommendations are as follows o Initiation of supine NIT and respiratory stabilization o 30-minute prone test on both HFNT and NIV/CPAP o If the patient is comfortable, hold until signs of position fatigue appear o Try to pronate at least twice a day

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• Pharmacological measures for adaptation and comfort to TNI § These are measures aimed at controlling tachypnoea and increasing the comfort and

adherence to patient’s treatment. § The primary objective is to reduce dyspnoea. § The secondary objective is the initial decrease in respiratory rate and to facilitate

adaptation to NIT. § Pharmacological measures depend on the experience of the physician and the safety

and monitoring environment in which the patient is located. § The administration of drugs should always be by IV in a titrated and progressive manner

until the effect of the drugs is evaluated. § Initial drug: Morphine IV in titrated 3mg boluses with a latency between repeat doses

of about 20-30 minutes. § Second line drugs: Remifentanil, Dexmetomidine in continuous infusion always in

controlled monitoring environments and handled by expert personnel. § Third line drugs: Propofol in continuous infusion always in controlled monitoring

environments and handled by expert personnel. § In any case, these recommendations can be adapted in relation to the protocols of

superficial sedation and pharmacological control of dyspnoea in each health centre.

• Ventilation systems in NIT § High Flow Nasal Therapy

o High flow therapy can be performed with different systems: ü HFNT with blenders and O2/Air flow meters connected to active

humidification systems ü HFNT with specialized turbines: Airvo-Airvo 2 (Fisher and Paykel) including

active humidifier ü HFNT in conventional critical ventilators connected to active humidification

systems ü HFNT on turbine ventilators (both NIV and IMV) connected to active

humidification systems o Since ventilators are to be used for invasive management (IMV) of patients, we

recommend the use of HFNT with mixer and flow meter systems, Airvo-Airvo 2 specialized turbine systems and NIV ventilators with included HFNT that are not to be used for IMV.

o In the case of HFNT with mixers and flowmeters, and since many hospital facilities do not have pressurized medical air intake, therapy can be performed only with high-flow O2 flowmeters. In this case the FiO2 will be raised to close to 1.

o NIV ventilators with HFNT included may allow rotation strategies of pulmonary protection therapies with minimal changes in the consumables used.

8

§ Non-mechanical CPAP systems (See Appendix) o Non-mechanical CPAP systems are a reasonable and efficient alternative for

treating hypoxemic patients. o Multi-purpose CPAP systems should be used that can be adapted to different

interfaces, allow the use of filtration systems, have the possibility of modifying the CPAP level without exchanging the resistance valve (to avoid disconnections), and do not require additional flow generators.

o The systems recommended in this clinical context are: ü Boussignac CPAP. You only need a 30 l/min or 15 l/min flowmeter with no

litre stop. It can be adapted to any interface, including a Helmet. CPAP levels can reach up to 20 cmH2O. (https://youtu.be/0H9OV7eUXQA)

ü Portable CPAP systems with variable resistance threshold: CPAP O2-MAX (P Pulmodyme), CPAP GO-PAP (Pulmodyme). These are systems with a maximum CPAP of 15 cm H2O. They can be adapted to different types of interface. They can be used with filtration systems

ü In any case, the non-mechanical CPAP systems available in each centre can be used following the safety regulations

§ NIV ventilators o NIV ventilators are in most cases turbines with a single-limb circuit, with leakage

compensation and expiratory hole. o There are models with turbine and double limb or expiratory valve system o Although the use of dual branch circuits is recommended to minimize the dispersion

of pathogenic aerosols, according to Spanish Ministry of Health standards and expert recommendations (23), we believe that with the adoption of safety measures at NIT, any type of respirator available to apply NIT can be safely used.

o We also recommend the possibility of using advanced NIV ventilators (V60, VIVO 50-55-60-65, Monnal T60 or similar) of a single branch for the realization of IMV in PCV or VCV mode (if available) with the adoption of the relevant safety measures.

• Security measures in NIT § NITs are considered to be high risk techniques for health personnel applying them

because of the possibility of dispersal of pathogens according to a technical document from the Spanish Ministry of Health dated March 3, 2020 (23). The following table summarizes all the procedures stratified by their risk:

Procedure with a Low Risk Viral Transmission Procedures with a High Risk of Viral Transmission

• Guedel airway placement • Oxygen therapy face mask with expiratory

filter • Chest compression • Defibrillation, cardioversion, transcutaneous

pacemaker placement • Arterial or venous line insertion • Administration of drugs or intravenous fluids

• Aerosol therapy, nebulization • High-flow nasal cannulas • Manual ventilation with mask • Non-invasive CPAP/BiPAP ventilation • Endotracheal intubation • Surgical Tracheotomy > Percutaneous • Bronchoscopy, gastroscopy • Suctioning of secretions • Cardiopulmonary resuscitation

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§ There is controversy about the dispersion of particles in NIT since the WHO document

(3) partially contradicts in its section number 5 the recommendations of Spanish the Ministry of Health (23).

§ As experts in NIT, we are not going to enter into this discussion and consider that in this emergency situation it is our responsibility to recommend safety guidelines for the application of NIT in hospital centres and to provide adequate training. Each healthcare centre should establish its own protocol for action and may take and/or adapt these recommendations in a relevant and consensual manner with all the professionals involved in patient care.

§ Considerations o All personnel who will attend patients with NIT must wear a personal protective

equipment (PPE) and the appropriate decontamination circuits in accordance with the protocols established in each centre.

o NIT involves working with leaks so all safety measures taken will be aimed at minimizing peri-interface leaks and filtering all leaks associated with the circuits and turbines of the ventilators.

o Active humidification systems for NIV/Non-mechanical CPAP systems are initially contraindicated as they are incompatible with filters and may cause condensation at the interfaces with the risk of dispersal of pathogens. Active humidification systems are key to handling secretions in hypoxemic patients and in view of their contraindication we recommend the use of interfaces that act as heat and moisture exchangers: Total Face (Performax) and Helmet.

o Active humidification systems for HFNT are not contraindicated because the dispersion and condensation of particles is very small.

o Before starting the NIT, make sure that all circuit connections are securely connected.

§ Filtration systems (24) (Aee Appendix)

o The definition of passive humidification and filtration systems is important as there may be confusion between the two with consequent serious safety failures.

o A filter is not the same as a passive humidification system - artificial nose - heated and moisture exchanger.

o They are known by their acronyms and on the labels of each one you should notice: FàFilter, HMEàHeated and Moisture Exchanger, HMEFàthe combination of the two. HME HAS NO FILTERING CAPACITY DO NOT USE.

o The following table summarizes the differences between the filter types (See Appendix):

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System Filtration Humidification Where to Connect Duration F (Filter)

YES • Recommended 99,99% • Optimum 99,999%

• Antibacterial/Antivirus • Mechanical or

Electrostatic

NO

• Between the mask and the circuit of the respirator or CPAP valve

• On the ventilator's inspiratory output

• At the expiratory entrance to the respirator

24 hours

average (see each

manufacturer's recommendation)

HMEF (Heated and Moisture Exchanger plus Filter))

YES • Recommended 99,99% • Optimum 99,999%

• Antibacterial/Antivirus • Mechanical or

Electrostatic

YES • Between 25-30

mgH2O/L of absolute humidity

• Hygroscopic membrane that increases humidity

• Can cause condensation on the interface

• Between the mask and the circuit of the respirator or CPAP valve

• Can increase circuit resistance more than filters alone

• Suitable forI MV connected directly to the tube

24 hours average

(see each manufacturer's

recommendation)

HME (Heated and Moisture Exchanger)

NO Never use in NIT

systems in patients with ARF who are

infectious

YES • Between 25-30

mgH2O/L of absolute humidity

• Hygroscopic membrane that increases humidity

• Can cause condensation on the interface

NO Never use NIT systems in

patients with ARF who are infectious

24 hours

average (see each

manufacturer's recommendation)

§ Safety measures for handling the interface o All interfaces must have a Filter or an HMEF connected to the elbow before starting

the NIV/CPAP. In the case of the Helmet, it must be connected in the proper connection holes, keeping the rest covered.

o Minimize circuit disconnections as much as possible. o Use interfaces with blue elbow without anti-asphyxia valve whenever possible. In

situations where the ventilator is disconnected or the flow of the flowmeters is absent, the patient can breathe through the valve and disperse aerosols. In this case non-pressurized dispersal occurs.

o Recommended elbows are blue or standard elbows without anti-asphyxia valve. o Non-mechanical CPAP systems in general can be connected to blue elbow

interfaces. o Most NIV ventilators with single-limb circuits work perfectly with blue elbows,

however, close observation is important to avoid interruption of gas flow. If gas flow is interrupted, simply disconnect the circuit by keeping the mask with the filter on the patient until the problem is resolved.

o Every time the interface is changed, it is advisable to do it between two people. It is essential to follow the steps below:

1) Stop the gas flow of the NIV/CPAP system (close the flow meters, turn off the respirator)

2) Leave the filter system in place at the patient interface

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3) Place a new filter in the new interface (usually in the elbow) 4) Connect the new filter interface to the ventilator circuit/CPAP system

and start pressurization 5) Remove the patient interface and quickly replace it with the new one by

tighten the straps firmly to minimize leakage

§ Safety measures for the management of High Flow Therapy (HFNT) o Place the high-flow nasal cannula on the patient with the entire active

humidification system and circuits connected without applying flow. o Once the system and cannulas are in place, start gas flow to the desired L/min

target (about 60 L/min). o Each time the nasal cannula is changed, turn off the gas flow. o Watch for condensation in the circuit and in the nasal cannula. The use of high-

quality nasal cannulas and circuits minimises condensation.

§ Safety measures for nebulization with NIT o Nebulized medication poses a high risk of viral transmission o Whenever possible, it is recommended to use MDI (Metered Dose Inhaler) drug

delivery systems through a volumetric chamber o Whenever possible, it is recommended to use Vibrating mesh systems

(Aerogen) o During NITs, especially NIV/CPAP, nebulization is unidirectional, so there is less

dispersion of particles as long as the system is pressurized and has minimal leakage

o Vibrating mesh systems (Aerogen) are more efficient than jet type systems, do not use additional gas source and generate less particle dispersion. In addition, they can be inserted into the circuit with minimal disconnections.

o The nebulized medication can be deposited on the filters generating their saturation so they have to be checked every time the nebulization is finished

o The security measures are as follows 1) Each time a jet nebulizer with a T-piece is inserted between the mask

and filter, the respirator and flow meters must be turned off 2) Then connect the T-piece directly to the interface 3) Start pressurization or gas flow from the flow meters 4) Start gas flow at 6 l/min from the nebulizer

o If the therapy has to be repeated, it is recommended to leave the T-piece firmly connected to avoid disconnections

o In the case of TAF, we recommend Aerogen Ultra® mouthpiece (vibrating mesh technology)

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INDICATIONS AND CONTRAINDICATIONS OF NIT CONTRAINDICATIONS ABSOLUTE

• Need to isolate airway/cardio-respiratory arrest • Severe anatomical obstruction/alteration in the upper airway • Poor secretion control/high risk of aspiration. • Threatening haemoptysis. • Inability to adapt any type of interface. • Patient refusal/lack of cooperation.

RELATIVE

• Uncontrollable hemodynamic shock/instability • Decreased level of consciousness (ECG < 8) • Unresolved pneumothorax. • Uncontrollable vomiting. • Uncontrollable hematemesis/epistaxis. • Pregnancy. • Lack of knowledge of the technique. • Initial inclusion criteria for NIT in rescue-prone patients with IMV • PaO2/FiO2 > 100 • Moderate to severe dyspnoea with signs of respiratory work and use of accessory

muscles or paradoxical abdominal movement • Tachypnoea greater than 30 rpm • Absence of multiorgan failure (APACHE <20). • Expert team with the possibility of applying VMI rescue on prepared units

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RISK FACTORS FOR NIT FAILURE RISK FACTORS FOR IMMEDIATE FAILURE (FIRST 30-60 M)

• Poor secretion control, decreased cough reflex. • Intolerance to technique, uncontrolled agitation. • Poor patient-ventilator adaptation; asynchronies. • Severe hypercapnic encephalopathy/hypercapnic coma. • High severity rates (APACHE, SOFA, SAPS). • PaO2/FiO2 onset < 150 mmHg. • FR of onset > 30 rpm

RISK FACTORS FOR EARLY FAILURE (FIRST 120 M) Hypoxemic ARF

• No improvement in PaO2/FiO2 (persists < 150 mmHg) and pH (< 7.30). • FR persists > 30 rpm. • Being a de novo ARF, having pneumonia, having ARDS, bilateral radiological worsening. • Deterioration of consciousness (ECG < 13). • Poor control of secretions, intolerance to the technique, need to use sedation. • Poor patient-ventilator adaptation; asynchronies. • Presence of shock, renal failure.

Hypercapnic ARF

• No improvement in PaO2/FiO2 (persists < 150 mmHg) and pH (< 7.30). • FR persists > 35 rpm. • Deterioration/non-improvement of consciousness (ECG < 13). • Poor control of secretions, intolerance to the technique, need to use sedation. • Poor patient-ventilator adaptation; asynchronies. • Others; anaemia, renal failure, malnutrition, hypo-K, colonization by gram-negative

bacilli in sputum/ bronchiectasis, need for high support pressures/ obtain current volumes > 500 ml.

RISK FACTORS FOR LATE FAILURE (>24 H)

• - Poor secretion control/impossibility of using active humidification • -Mask intolerance/lack of protection/no possibility to rotate interfaces • - Appearance of pressure ulcers • - Worsening of initial illness/appearance of clinical complication • - Lack of trained personnel.

TREATMENT ALGORITHM

Alg

orit

hm o

f man

agem

ent

of N

IT in

ARF

COV

ID-1

9

RR>2

8-32

bm

p, S

pO2<

90%

PaO

2/Fi

O2

<200

, pCO

2<4

5(F

iO2

> 0.

4 fo

r Sp

O2

≤92%

) D

ysne

a m

ild-s

ever

e

Earl

y on

set

HFN

T50

-60

l/m

inFi

O2

0,8-

0,9

Vent

ilato

ry A

lert

Pr

otoc

olIC

U e

valu

atio

n

Tran

sfer

to IC

UIn

vasi

ve V

entil

atio

n M

anag

emen

t (IM

V)N

o in

dica

tion

for

ICU

adm

issi

on

Vent

ilato

ry S

uppo

rtN

on-In

vasi

ve

Resp

irato

ry T

hera

pies

(NIT

)

HFN

T

50-6

0 L/

min

FiO

20,

8-0,

9

BiPA

P/PS

CPA

P

Onl

y in

cas

e fo

r H

yper

capn

ia

EPAP

/PEE

P/CP

AP 1

0-14

cm

H 2O

PS 5

cm

H 2O

max

imum

FiO

20,

8-0,

9

CPAP

10-

14

cmH 2

O

FiO

20,

8-0,

9N

on-M

echa

nica

l Sy

stem

s or

V

entil

ator

Rota

tion

of L

ung

Prot

ectiv

e Th

erap

ies

Eval

uate

clin

ical

cou

rse

and

tole

ranc

epr

efer

red

CPA

P/H

FNT

Mas

k Ro

tatio

n St

rate

gy

Firs

t Lin

e Bl

ue E

lbow

Perf

orm

axor

Hel

met

Pr

efer

red

Eval

uate

Inte

rfac

e Ro

tatio

n ev

ery

6-8

hour

sA

sses

s ad

vers

e ef

fect

sN

ursi

ng c

are

Art

eria

l blo

od g

as a

nd

Clin

ical

eva

luat

ion

at

60 a

nd 1

20 m

inut

es

afte

r on

set

the

ther

apy

Impr

ovem

ent

afte

r 12

0 m

inRR

<25

Mild

Dys

nea

PaO

2/Fi

O2>

200

No

impr

ovem

ent

Aft

er 1

20 m

in

Vent

ilato

r fo

r IM

V av

aila

ble?

YES

NO

Keep

on

Rota

tion

of L

ung

Prot

ectiv

e Th

erap

ies

Incr

ease

CPA

P 15

-16

cm H

2OIn

crea

se H

FNT

up to

80

l/m

inAs

sess

to

switc

h to

CPA

PAs

sess

NIT

in

PRO

NE

POSI

TIO

N

Safe

ty S

trat

egy

in N

on-In

vasi

ve T

hera

pies

•M

inim

ize d

iscon

nect

ions

•Ad

just

pro

perly

inte

rface

/ na

sal c

annu

la

to re

duce

leak

age

•Al

way

s wea

r PPE

•Tu

rn o

ff ve

ntila

tor a

nd fl

owm

eter

s on

each

rota

tion

•Us

e Fi

lters

in e

xpira

tory

and

insp

irato

ry

port

s of t

he v

entil

ator

•Us

e fil

ters

bet

wee

n in

terfa

ce a

nd C

PAP

valv

e / r

espi

rato

r circ

uit

Tran

sfer

to IC

UN

IT M

anag

emen

tSe

lect

ed C

ases

RR>2

8-32

rm

p, S

pO2<

90%

PaO

2/Fi

O2

<200

pH

<7.3

5/PC

O2

>45

(FiO

2 >

0.4

for

SpO

2≤9

2%)

Dys

nea

mild

-sev

ere

Earl

y on

set N

IVLu

ng P

rote

ctiv

e Th

erap

yFi

O2

0,8-

0,9

Do-

not

Intu

bate

O

rder

NO

YES

Res

pira

tory

Car

eVa

lenc

ia

Non

Inva

sive

Vent

ilatio

n

NIV

RC

Vale

ncia

Gro

up

NIV

-RC

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up

Spain

Cons

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ear

ly

NIT

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PRO

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POSI

TIO

N

REFERENCES 1. Guan W, Ni Z, Hu Y, Liang W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J

Med 2020. DOI: 10.1056/NEJMoa2002032.

2. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult

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