Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 24 , ISSUE 10 ( October, 2020 ) > List of Articles

Original Article

Non-invasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey

Ashwin Subramaniam, Jumana Y Haji, Kollengode Ramanathan, Arvind Rajamani

Keywords : Conservative oxygen therapy, COVID-19, High flow nasal cannula oxygen therapy, Hypoxemia, Indian intensive care unit, Low flow nasal oxygen, NIV: Noninvasive mechanical ventilation, SARS-COV-2

Citation Information : Subramaniam A, Haji JY, Ramanathan K, Rajamani A. Non-invasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey. Indian J Crit Care Med 2020; 24 (10):926-931.

DOI: 10.5005/jp-journals-10071-23640

License: CC BY-NC 4.0

Published Online: 30-10-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Background: About 5% of hospitalized coronavirus disease 2019 (COVID-19) patients will need intensive care unit (ICU) admission for hypoxemic respiratory failure requiring oxygen support. The choice between early mechanical ventilation and noninvasive oxygen therapies, such as, high-flow nasal oxygen (HFNO) and/or noninvasive positive-pressure ventilation (NPPV) has to balance the contradictory priorities of protecting healthcare workers by minimizing aerosol-generation and optimizing resource management. This survey over two timeframes aimed to explore the controversial issue of location and noninvasive oxygen therapy in non-intubated ICU patients using a clinical vignette. Materials and methods: An online survey was designed, piloted, and distributed electronically to Indian intensivists/anesthetists, from Private Hospitals, Government Hospitals, and Medical College Hospitals (the latter two referred to as first-responder hospitals), who are directly responsible for admitting/managing patients in ICU. Results: Of the 204 responses (125/481 in phase 1 and 79/320 in phase 2), 183 responses were included. Respondents from first-responder hospitals were more willing to manage non-intubated hypoxemic patients in neutral pressure rooms, while respondents from private hospitals preferred negative-pressure rooms (p < 0.001). In both the phases, private hospital doctors were less comfortable to use any form of noninvasive oxygen therapies in neutral-pressure rooms compared to first-responder hospitals (low-flow oxygen therapy: 72 vs 50%, p < 0.01; HFNO: 47 vs 24%, p < 0.01 and NPPV: 38 vs 28%, p = 0.20). Interpretation: Variations existed in practices among first-responder and private intensivists/anesthetists. The resource optimal private hospital intensivists/anesthetists were less comfortable using noninvasive oxygen therapies in managing COVID-19 patients. This may reflect differential resource availability necessitating resolution at national, state, and local levels.


  1. Coronavirus disease (COVID-19) - Situation Report #155. World Health Organisation, 2020. (Accessed June 24th 2020, 2020, at Coronavirus disease (COVID-19).).
  2. Phua J, Weng L, Ling L, Egi M, Lim PC-M, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020;8(5):506–517. DOI: 10.1016/S2213-2600(20)30161-2.
  3. Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM guidelines for the use of non-invasive ventilation in acute respiratory failure in adult ICUs. Indian J Crit Care Med 2020;24:S61–s81.
  4. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020;323(18):1775–1776. DOI: 10.1001/jama.2020.4683.
  5. Pivoting Critical Care Research to Help with the COVID-19 Pandemic. Newswise, 2020. (Accessed June 24th 2020, at https://www.newswise.com/coronavirus/pivoting-critical-care-research-to-help-with-the-covid-19-pandemic/?article_id=730343.).
  6. Leung CCH, Joynt GM, Gomersall CD, Wong WT, Lee A, Ling L, et al. Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: a randomized controlled crossover trial. J Hosp Infect 2019;101(1):84–87. DOI: 10.1016/j.jhin.2018.10.007.
  7. Loh NHW, Tan Y, Taculod J, Gorospe B, Teope AS, Somani J, et al. The impact of high-flow nasal cannula (HFNC) on coughing distance: implications on its use during the novel coronavirus disease outbreak. Can J Anaesth 2020;67(7):893–894. DOI: 10.1007/s12630-020-01634-3.
  8. McGain F, Humphries RS, Lee JH, Schofield R, French C, Keywood MD, et al. Aerosol generation related to respiratory interventions and the effectiveness of a personal ventilation hood. Crit Care Resusc 2020. Online ahead of print.
  9. Iwashyna TJ, Boehman A, Capelcelatro J, Cohn AM, Cooke JM, Costa DK, et al. Variation in aerosol production across oxygen delivery devices in spontaneously breathing human subjects. medRxiv 2020. DOI: 2020.04.15.20066688.
  10. Li J, Fink JB, Ehrmann S. High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion. Eur Respir J 2020;55(5):2000892. DOI: 10.1183/13993003.00892-2020.
  11. ANZICS COVID-19 Guidelines. Australian and New Zealand Intensive Care Society (ANZICS), 2020. (Accessed March 31 2020, 2020, at https://www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf.).
  12. Kluge S, Janssens U, Welte T, Weber-Carstens S, Marx G, Karagiannidis C. German recommendations for critically ill patients with COVID-19. Medizinische Klinik, Intensivmedizin und Notfallmedizin 2020. 1–4. DOI: 10.1007/s00063-020-00689-w.
  13. Effectiveness of different forms of oxygen therapy for COVID-19 management. World Health Organization, 2020. (Accessed June 15, 2020, at https://apps.who.int/iris/bitstream/handle/10665/332305/WHO-AF-ARD-DAK-04-2020-eng.pdf?sequence=3&isAllowed=y.).
  14. Kumar P, Kumar M. Management of potential ventilator shortage in India in view of on-going COVID-19 pandemic. Indian J Anaesth 2020;64(14):151–152. DOI: 10.4103/ija.IJA_342_20.
  15. Ozair A, Agrawal A, Siddiqui SS. Training and delivery of critical care medicine in India: concerns revealed by COVID-19 pandemic. Indian J Crit Care Med 2020;24(4):285–286. DOI: 10.5005/jp-journals-10071-23404.
  16. Pandey T. No need to clap, but don't shut our voices: Doctors flag backlash for speaking out. India Today 2020 07/04/2020.
  17. Murthy PR, Gupta KV, Ajith Kumar AK. Is anxiety a rising concern during COVID-19 pandemic among healthcare workers? Indian J Crit Care Med 2020;24(5):369–370. DOI: 10.5005/jp-journals-10071-23434.
  18. Rajamani A, Subramaniam A, Shekar K, Haji J, Luo J, Bihari S, et al. On behalf of the SPARTAN collaborative - small projects, audits, research trials - Australia/New Zealand, personal protective equipment preparedness in Asia-Pacific intensive care units during the COVID-19 pandemic: A multinational survey, Australian critical care. DOI: 10.1016/j.aucc.2020.09.006.
  19. Haji JY, Subramaniam A, Kumar P, Ramanathan K, Rajamani A. The state of personal protective equipment practice in Indian intensive care units amidst COVID-19 pandemic: A nationwide survey. Indian J Crit Care Med 2020;24(9):809–816.
  20. Thacker TSN, Covid-19 in India: Cautious government involves private sector in treating patients. Economic Times 2020.
  21. Morawska L, Milton DK. It is time to address airborne transmission of COVID-19. Clin Infect Dis 2020. ciaa939. DOI: 10.1093/cid/ciaa939.
  22. World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations: scientific brief, 29 March 2020. Geneva: World Health Organization; 2020.
  23. Transmission of SARS-CoV-2: implications for infection prevention precautions. 2020. (Accessed July 11th, 2020, at https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions.).
  24. PTI. India becomes world's second largest manufacturer of PPE bod. Read more at: http://timesofindia.indiatimes.com/articleshow/75871010.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst. Times of India 2020 May 21.
  25. Sarin R, As Covid curve rises, surge in ventilators causes glut. The Indian Express 2020.
  26. Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical care for COVID-19 affected patients: position statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(4):222–241. DOI: 10.5005/jp-journals-10071-23395.
  27. Jumbo SJ. NSCI Dome facility set to turn into COVID-19 hospital. The Hindu 2020 May 25th 2020.
  28. Aljazeera, Delhi opens makeshift 10,000-bbed hospital amid coronavirus surge. Aljazeera 2020 July 2nd 2020.
  29. Kumar A, Kumar A, Kumar N, Kumar A, Singh PK. Modified oxygen therapy device for prevention of aerosol dispersion in COVID-19 patients. J Clin Anesth 2020;65:109884. DOI: 10.1016/j.jclinane.2020.109884.
  30. Ing RJ, Bills C, Merritt G, Ragusa R, Bremner RM, Bellia F. Role of helmet-delivered noninvasive pressure support ventilation in COVID-19 patients. J Cardiothorac Vasc Anesth 2020;34(10):2575–2579. DOI: 10.1053/j.jvca.2020.04.060.
  31. Prendergast K. Ventilation hoods for ICU beds to protect healthcare workers. Nursing Review 2020 17/04/2020.
  32. Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the COVID-19 pandemic. Acad Emerg Med 2020;27(5):375–378. DOI: 10.1111/acem.13994.
  33. Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med 2020;8(8):P765–P774. DOI: 10.1016/S2213-2600(20)30268-X.
  34. Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care 2020;24(1):28. DOI: 10.1186/s13054-020-2738-5.
  35. Elharrar X, Trigui Y, Dols AM, Touchon F, Martinez S, Prud'homme E, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA 2020;323(22):2336–2338. DOI: 10.1001/jama.2020.8255.
  36. Jiang LG, LeBaron J, Bodnar D, Caputo ND, Chang BP, Chiricolo G, et al. Conscious proning: an introduction of a proning protocol for nonintubated, awake, hypoxic emergency department COVID-19 patients. Acad Emerg Med 2020;27(7):566–569. DOI: 10.1111/acem.14035.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.