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| ==Overview==
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| The feasibility of the strategy used for the management of a [[patient]] with [[COVID-19]] depends on the patients' condition at the time of presentation. Continuous evaluation and titration of ongoing interventions ensure optimal results. The respiratory manifestations of [[COVID-19]] may require some oxygen supplementation to [[ventilation|ventilatory support]]. Autopsy findings of [[patients]] with [[COVID-19-associated acute respiratory distress syndrome]] (CARDS) demonstrated small airway occlusion due to [[necrosis]] and [[inflammation]]. The finding advocates the use of [[positive pressure ventilation]] to restore the collapsed airways. A balanced approach is required as a high end-inspiratory pressure increases the risk of lung [[alveoli|alveolar]] injury.<ref name="pmid32506258">{{cite journal |vauthors=Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D |title=Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China |journal=Ann Intensive Care |volume=10 |issue=1 |pages=73 |date=June 2020 |pmid=32506258 |pmc=7275657 |doi=10.1186/s13613-020-00689-1 |url=}}</ref>
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| ==Ventilatory support in COVID-19==
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| *The [[COVID-19]] respiratory complications that may require mechanical [[ventilation]] include: [[COVID-19-associated pneumonia]], [[COVID-19-associated acute respiratory distress syndrome]] (CARDS) and [[COVID-19-associated respiratory failure]]. At the start, the recommendation to treat [[COVID-19-associated acute respiratory distress syndrome|CARDS]] was similar to the ones used to treat [[ARDS]] due to other causes. During the initial course of the disease, in the absence of bacterial [[infection]] in [[COVID-19-associated pneumonia]] or [[COVID-19-associated acute respiratory distress syndrome|CARDS]], the patient has normal or even high pulmonary [[compliance]]. Thus, a patient can have severe [[hypoxemia]] in the absence of [[tachypnoea]] or [[dyspnea]]. Knowledge and experience of the unique features of the disease have led the guidelines to be modified/ specified.
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| * Acute hypoxemic [[respiratory failure]] and [[ARDS]] are more common respiratory complications in [[COVID-19]] patients.<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| ===Supplemental Oxygen===
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| *A patient with L (low lung elastance and [[Ventilation/perfusion ratio|V/Q ratio]]) type of [[COVID-19-associated pneumonia]] or [[COVID-19-associated acute respiratory distress syndrome|CARDS]] benefit from increased [[FiO2]] the most. The therapy is particularly useful if the [[patient]] is non-[[dyspnea|dyspnic]].<ref name="pmid32291463">{{cite journal |vauthors=Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, Camporota L |title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? |journal=Intensive Care Med |volume=46 |issue=6 |pages=1099–1102 |date=June 2020 |pmid=32291463 |pmc=7154064 |doi=10.1007/s00134-020-06033-2 |url=}}</ref>
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| *In [[COVID-19|SARS Cov2]] positive adult [[patients]] the Surviving Sepsis Campaign (SSC) strongly recommendeds (with moderate-quality evidence):<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| ** To start the [[oxygen therapy|supplemental oxygen]] if the [[oxygen saturation|Spo2]] is < 90%. Starting the supplemental oxygen at < 92% saturation has weak recommendation.
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| ** Maintain [[oxygen saturation|Spo2]] no higher than 96% in [[patients]] with with acute [[respiratory failure|hypoxemic respiratory failure]] on [[oxygen therapy|supplemental oxygen therapy]]. The recommendation is based upon the systematic review and meta-analysis of 25 [[Randomized controlled trial|RCTs]] that showed a linear association between the death risk and higher [[oxygen saturation|Spo2]] targets.
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| ===Non-Invasive ventilation (NIV)===
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| *NIV methods are easier and comfortable to use and work by inducing [[PEEP]] thus decreased the respiratory workload. Based on the [[COVID-19]] experience of the Chinese experts , both HFNC and [[Positive airway pressure|NIPPV]] methods should probably be utilized in patients with [[Hypoxemia laboratory findings|PaO2/FiO2]] > 150 mmHg.<ref name="pmid32506258">{{cite journal |vauthors=Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D |title=Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China |journal=Ann Intensive Care |volume=10 |issue=1 |pages=73 |date=June 2020 |pmid=32506258 |pmc=7275657 |doi=10.1186/s13613-020-00689-1 |url=}}</ref>
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| *Close monitoring for a deteriorating respiratory status and early [[intubation]] when indicated in a controlled setting, can help minimize the [[infection]] of health personnel and promise better [[patient]] health outcomes.<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| *Inspiratory pressures should be 10 cmH2O and expiratory pressures be 5 cmH2O with 1.0 [[FiO2]].<ref name="urlOxygenation and Ventilation of COVID 19 Patients | American Heart Association CPR & First Aid">{{cite web |url=https://cpr.heart.org/en/resources/coronavirus-covid19-resources-for-cpr-training/oxygenation-and-ventilation-of-covid-19-patients |title=Oxygenation and Ventilation of COVID 19 Patients | American Heart Association CPR & First Aid |format= |work= |accessdate=}}</ref>
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| ====High Flow Nasal Cannula (HFNC)====
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| *Also known as high flow nasal oxygen (HFNO) or Heated humidified high-flow (HHHF) therapy is a non-invasive technique. It is a technique of delivering heated and humidified high-flow oxygen via soft and flexible nasal prongs. Humidification prevents the drying of [[epithelium]] and facilitates the removal of [[mucosa]]l secretions. Other advantages include pharyngeal [[dead space]] washout and [[PEEP]] effect.<ref name="pmid27698207">{{cite journal |vauthors=Zhang J, Lin L, Pan K, Zhou J, Huang X |title=High-flow nasal cannula therapy for adult patients |journal=J. Int. Med. Res. |volume=44 |issue=6 |pages=1200–1211 |date=December 2016 |pmid=27698207 |pmc=5536739 |doi=10.1177/0300060516664621 |url=}}</ref> A [[hypercapnic]] patient should not be administered HFNC.
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| *Sufficient evidence to prove the superiority of one of the methods (HFNC or [[Positive airway pressure|NIPPV]]) is lacking. But HFNC is preferred over [[Positive airway pressure|Non-invasive positive pressure ventilation (NIPPV)]]. It is possibly due to reduced [[mortality rate|mortality]] and decreased [[intubation]] risk, as proved by a [[Randomized controlled trial|RCT]] and a meta-analysis respectively. [[Patient]] comfort better oxygenation with HFNC than [[Positive airway pressure|NIPPV]] is also one of the considering factors.<ref name="pmid32506258">{{cite journal |vauthors=Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D |title=Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China |journal=Ann Intensive Care |volume=10 |issue=1 |pages=73 |date=June 2020 |pmid=32506258 |pmc=7275657 |doi=10.1186/s13613-020-00689-1 |url=}}</ref><ref name="FratThille2015">{{cite journal|last1=Frat|first1=Jean-Pierre|last2=Thille|first2=Arnaud W.|last3=Mercat|first3=Alain|last4=Girault|first4=Christophe|last5=Ragot|first5=Stéphanie|last6=Perbet|first6=Sébastien|last7=Prat|first7=Gwénael|last8=Boulain|first8=Thierry|last9=Morawiec|first9=Elise|last10=Cottereau|first10=Alice|last11=Devaquet|first11=Jérôme|last12=Nseir|first12=Saad|last13=Razazi|first13=Keyvan|last14=Mira|first14=Jean-Paul|last15=Argaud|first15=Laurent|last16=Chakarian|first16=Jean-Charles|last17=Ricard|first17=Jean-Damien|last18=Wittebole|first18=Xavier|last19=Chevalier|first19=Stéphanie|last20=Herbland|first20=Alexandre|last21=Fartoukh|first21=Muriel|last22=Constantin|first22=Jean-Michel|last23=Tonnelier|first23=Jean-Marie|last24=Pierrot|first24=Marc|last25=Mathonnet|first25=Armelle|last26=Béduneau|first26=Gaëtan|last27=Delétage-Métreau|first27=Céline|last28=Richard|first28=Jean-Christophe M.|last29=Brochard|first29=Laurent|last30=Robert|first30=René|title=High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure|journal=New England Journal of Medicine|volume=372|issue=23|year=2015|pages=2185–2196|issn=0028-4793|doi=10.1056/NEJMoa1503326}}</ref>
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| *In acute [[respiratory failure|hypoxemic respiratory failure]] despite [[oxygen therapy|supplemental oxygen therapy]], SSC suggests using HFNC over conventional [[oxygen therapy]] (weak recommendation). A systematic review and meta-analysis of 9 [[Randomized controlled trial|RCTs]] showed that High Flow Nasal Cannula (HFNC) reduces the need for [[intubation]].<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yasadult een M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| *Target SpO2 should be 88% -94% with minimal flow rates under 30L/min. Low flow rates help minimize aerosolization. [[PEEP]] ranges from 5-15 and peak airway pressure ranges from 8-10 cmH2O.<ref name="urlOxygenation and Ventilation of COVID 19 Patients | American Heart Association CPR & First Aid">{{cite web |url=https://cpr.heart.org/en/resources/coronavirus-covid19-resources-for-cpr-training/oxygenation-and-ventilation-of-covid-19-patients |title=Oxygenation and Ventilation of COVID 19 Patients | American Heart Association CPR & First Aid |format= |work= |accessdate=}}</ref>
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| ====Non-Invasive Positive Pressure Ventilation (NIPPV)====
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| *[[Positive airway pressure|Non-invasive positive pressure ventilation (NIPPV)]] is a technique utilized for delivering [[mechanical ventilation]] without the use of [[endotracheal intubation]] or [[tracheostomy]]. It can be administered through a [[Oxygen mask|face mask]], nasal mask, or a helmet and includes [[Positive airway pressure#Types|CPAP and BiPAP]].
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| *Many patients who develop [[ARDS]] receive a trial of [[Positive airway pressure|non-invasive positive pressure ventilation (NIPPV)]] before [[intubation]] for [[mechanical ventilation]] before they clinically deteriorate or become unable to maintain adequate [[oxygenation]]. Studies from China reported (4% to 13%) of [[COVID-19]] patients to have received [[Positive airway pressure|NIPPV]].<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| *In adults with [[COVID-19]] and [[respiratory failure|hypoxemic respiratory failure]], if HFNC is not available and [[endotracheal intubation]] not urgently indicated, a trial of [[Positive airway pressure|NIPPV]] can be given. Type L patients with [[dyspnea]] can benefit from NIV.<ref name="pmid32291463">{{cite journal |vauthors=Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, Camporota L |title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? |journal=Intensive Care Med |volume=46 |issue=6 |pages=1099–1102 |date=June 2020 |pmid=32291463 |pmc=7154064 |doi=10.1007/s00134-020-06033-2 |url=}}</ref> Close monitoring and short-interval assessment for worsening of [[respiratory failure]] is required. (weak recommendation by SSC).<ref name="AlhazzaniMøller2020">{{cite journal|last1=Alhazzani|first1=Waleed|last2=Møller|first2=Morten Hylander|last3=Arabi|first3=Yaseen M.|last4=Loeb|first4=Mark|last5=Gong|first5=Michelle Ng|last6=Fan|first6=Eddy|last7=Oczkowski|first7=Simon|last8=Levy|first8=Mitchell M.|last9=Derde|first9=Lennie|last10=Dzierba|first10=Amy|last11=Du|first11=Bin|last12=Aboodi|first12=Michael|last13=Wunsch|first13=Hannah|last14=Cecconi|first14=Maurizio|last15=Koh|first15=Younsuck|last16=Chertow|first16=Daniel S.|last17=Maitland|first17=Kathryn|last18=Alshamsi|first18=Fayez|last19=Belley-Cote|first19=Emilie|last20=Greco|first20=Massimiliano|last21=Laundy|first21=Matthew|last22=Morgan|first22=Jill S.|last23=Kesecioglu|first23=Jozef|last24=McGeer|first24=Allison|last25=Mermel|first25=Leonard|last26=Mammen|first26=Manoj J.|last27=Alexander|first27=Paul E.|last28=Arrington|first28=Amy|last29=Centofanti|first29=John E.|last30=Citerio|first30=Giuseppe|last31=Baw|first31=Bandar|last32=Memish|first32=Ziad A.|last33=Hammond|first33=Naomi|last34=Hayden|first34=Frederick G.|last35=Evans|first35=Laura|last36=Rhodes|first36=Andrew|title=Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)|journal=Critical Care Medicine|volume=48|issue=6|year=2020|pages=e440–e469|issn=0090-3493|doi=10.1097/CCM.0000000000004363}}</ref>
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| *The safety and efficacy of helmet [[Positive airway pressure|NIPPV]] in [[COVID-19|SARS Cov2]] patients is questionable. One study advocates the use of helmet [[Positive airway pressure|NIPPV]] in [[COVID-19]] care due to potential avoidance of air dispersion through the spring-valve.<ref name="pmid32059800">{{cite journal |vauthors=Cabrini L, Landoni G, Zangrillo A |title=Minimise nosocomial spread of 2019-nCoV when treating acute respiratory failure |journal=Lancet |volume=395 |issue=10225 |pages=685 |date=February 2020 |pmid=32059800 |pmc=7137083 |doi=10.1016/S0140-6736(20)30359-7 |url=}}</ref> Having said that, the cost of a helmet may be an essential consideration for healthcare systems struggling financially.
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| ===Invasive Mechanical Ventilation (IMV)===
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| *The vascular [[endothelium|endothelial]] injury in [[COVID-19-associated acute respiratory distress syndrome]] (CARDS) and diverse [[mortality rate]]s across the world in [[COVID-19-associated acute respiratory distress syndrome|CARDS]] patients arbitrates the importance of different [[mechanical ventilation]] strategies.
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| *The Chinese [[CDC]] reports the case-fatality rate to be higher than 50% in [[patients]] who received invasive [[mechanical ventilation]].<ref name="WuMcGoogan2020">{{cite journal|last1=Wu|first1=Zunyou|last2=McGoogan|first2=Jennifer M.|title=Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China|journal=JAMA|volume=323|issue=13|year=2020|pages=1239|issn=0098-7484|doi=10.1001/jama.2020.2648}}</ref>
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| *According to the American Society of Anesthesiology based upon the experience of Chinese anesthesiologists, timely (neither premature nor late) [[intubation]] and ventilation most effectual breathing assistance.<ref name="urlStrategies for health care response to COVID-19 shared by Chinese anesthesiologists">{{cite web |url=https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/strategies-for-health-care-response-to-covid-19-shared-by-chinese-anesthesiologists |title=Strategies for health care response to COVID-19 shared by Chinese anesthesiologists |format= |work= |accessdate=}}</ref> Early [[intubation]] may prevent the transition from type L (low elastance and [[Ventilation/perfusion ratio|V/Q ratio]]) to (high elastance and [[Ventilation/perfusion ratio|V/Q ratio]]) phenotype of [[COVID-19-associated acute respiratory distress syndrome|CARDS]].<ref name="pmid32291463">{{cite journal |vauthors=Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, Camporota L |title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? |journal=Intensive Care Med |volume=46 |issue=6 |pages=1099–1102 |date=June 2020 |pmid=32291463 |pmc=7154064 |doi=10.1007/s00134-020-06033-2 |url=}}</ref>
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| ====Intubation====
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| According to [[Americal Heart Association]] (AHA), [[intubation]] is indicated in:
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| *'''Gas exchange abnormality''': [[Respiratory failure]] (usually hypoxic in [[COVID-19]]), [[Hypoxemia laboratory findings|PaO2/FiO2]] <150 (corrected for altitude), NIV with [[FiO2]] >0.6 and inability to maintain SpO2 >90%, unresponsiveness to HFNC therapy, [[hypercapnia]] ([[PaCO2]] > 45 mm Hg) with [[acidosis]] (PH< 7.3), increased work of breathing with deteriorating respiratory function.
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| *'''Airway protection''': [[Alterened mental status]] and neurological dysfuntions.
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| *'''Pulmonary toilet''': To remove excessive pulmonary secretions.
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| ====Ventilator settings====
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| The following ventilator setting should be used:<ref name="MengQiu2020">{{cite journal|last1=Meng|first1=Lingzhong|last2=Qiu|first2=Haibo|last3=Wan|first3=Li|last4=Ai|first4=Yuhang|last5=Xue|first5=Zhanggang|last6=Guo|first6=Qulian|last7=Deshpande|first7=Ranjit|last8=Zhang|first8=Lina|last9=Meng|first9=Jie|last10=Tong|first10=Chuanyao|last11=Liu|first11=Hong|last12=Xiong|first12=Lize|title=Intubation and Ventilation amid the COVID-19 Outbreak|journal=Anesthesiology|volume=132|issue=6|year=2020|pages=1317–1332|issn=0003-3022|doi=10.1097/ALN.0000000000003296}}</ref><ref name="urlNHLBI ARDS Network | Tools">{{cite web |url=http://www.ardsnet.org/tools.shtml |title=NHLBI ARDS Network | Tools |format= |work= |accessdate=}}</ref><ref name="FanDel Sorbo2017">{{cite journal|last1=Fan|first1=Eddy|last2=Del Sorbo|first2=Lorenzo|last3=Goligher|first3=Ewan C.|last4=Hodgson|first4=Carol L.|last5=Munshi|first5=Laveena|last6=Walkey|first6=Allan J.|last7=Adhikari|first7=Neill K. J.|last8=Amato|first8=Marcelo B. P.|last9=Branson|first9=Richard|last10=Brower|first10=Roy G.|last11=Ferguson|first11=Niall D.|last12=Gajic|first12=Ognjen|last13=Gattinoni|first13=Luciano|last14=Hess|first14=Dean|last15=Mancebo|first15=Jordi|last16=Meade|first16=Maureen O.|last17=McAuley|first17=Daniel F.|last18=Pesenti|first18=Antonio|last19=Ranieri|first19=V. Marco|last20=Rubenfeld|first20=Gordon D.|last21=Rubin|first21=Eileen|last22=Seckel|first22=Maureen|last23=Slutsky|first23=Arthur S.|last24=Talmor|first24=Daniel|last25=Thompson|first25=B. Taylor|last26=Wunsch|first26=Hannah|last27=Uleryk|first27=Elizabeth|last28=Brozek|first28=Jan|last29=Brochard|first29=Laurent J.|title=An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome|journal=American Journal of Respiratory and Critical Care Medicine|volume=195|issue=9|year=2017|pages=1253–1263|issn=1073-449X|doi=10.1164/rccm.201703-0548ST}}</ref>
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| *'''Mode''': No mode of ventilation has been suggested to be superior to others. [[American Heart Association|AHA]] recommends assist control PRVC.
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| *''[[Respiratory rate]]'': 20-25 breaths/min.
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| *'''[[Lung volumes#Measurement and values|Tidal volume]] (Vt)''': 4–8 ml/kg predicted body weight and lower inspiratory pressures. Excess Vt causes alveolar overdistension and worse [[COVID-19-associated acute respiratory distress syndrome|CARDS]].
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| * '''Plateau pressure''' (Pplat): <30 cm H2O and peak inspiratory pressure:<35 cmH2O.
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| *'''[[FiO2]]''': <0.6
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| *'''[[Positive end-expiratory pressure|Positive end-expiratory pressure (PEEP)]]''': Based upon the data of 8 [[RCT]]s on [[ARDS]], mean ± SD [[PEEP]] was 15.1 ± 3.6 cm H2O (higher) versus 9.1 ± 2.7 cm H2O (lower). Patients receiving higher [[PEEP]] had better oxygenation ([[PaO2/FiO2]]). It is recommended that moderate or severe [[COVID-19-associated acute respiratory distress syndrome|CARDS]] patients receive higher levels of [[PEEP]].<ref name="FanDel Sorbo2017">{{cite journal|last1=Fan|first1=Eddy|last2=Del Sorbo|first2=Lorenzo|last3=Goligher|first3=Ewan C.|last4=Hodgson|first4=Carol L.|last5=Munshi|first5=Laveena|last6=Walkey|first6=Allan J.|last7=Adhikari|first7=Neill K. J.|last8=Amato|first8=Marcelo B. P.|last9=Branson|first9=Richard|last10=Brower|first10=Roy G.|last11=Ferguson|first11=Niall D.|last12=Gajic|first12=Ognjen|last13=Gattinoni|first13=Luciano|last14=Hess|first14=Dean|last15=Mancebo|first15=Jordi|last16=Meade|first16=Maureen O.|last17=McAuley|first17=Daniel F.|last18=Pesenti|first18=Antonio|last19=Ranieri|first19=V. Marco|last20=Rubenfeld|first20=Gordon D.|last21=Rubin|first21=Eileen|last22=Seckel|first22=Maureen|last23=Slutsky|first23=Arthur S.|last24=Talmor|first24=Daniel|last25=Thompson|first25=B. Taylor|last26=Wunsch|first26=Hannah|last27=Uleryk|first27=Elizabeth|last28=Brozek|first28=Jan|last29=Brochard|first29=Laurent J.|title=An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome|journal=American Journal of Respiratory and Critical Care Medicine|volume=195|issue=9|year=2017|pages=1253–1263|issn=1073-449X|doi=10.1164/rccm.201703-0548ST}}</ref>
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| **''Titration for CARDS'': After lung recruitment maneuvers, [[PEEP]] can be titrated down from a maximum of 20 cm H2O until the goals of [[oxygenation]], plateau pressure, and [[compliance]] are all achieved. In Wuhan, [[COID-19]] patients with acute hypoxemic [[respiratory failure]] showed a poor tolerance to high [[PEEP]], possibly due to the severe lung damage by the [[SARS-CoV-2]] virus and [[inflammation|inflammatory]] reactions. The [[PEEP]] should be reduced to 8–10 cmH2O in [[Mechanical ventilation initial ventilator settings#Proning|prone positioning ventilation]]. <ref name="pmid32291463">{{cite journal |vauthors=Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, Camporota L |title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? |journal=Intensive Care Med |volume=46 |issue=6 |pages=1099–1102 |date=June 2020 |pmid=32291463 |pmc=7154064 |doi=10.1007/s00134-020-06033-2 |url=}}</ref><ref name="MengQiu2020">{{cite journal|last1=Meng|first1=Lingzhong|last2=Qiu|first2=Haibo|last3=Wan|first3=Li|last4=Ai|first4=Yuhang|last5=Xue|first5=Zhanggang|last6=Guo|first6=Qulian|last7=Deshpande|first7=Ranjit|last8=Zhang|first8=Lina|last9=Meng|first9=Jie|last10=Tong|first10=Chuanyao|last11=Liu|first11=Hong|last12=Xiong|first12=Lize|title=Intubation and Ventilation amid the COVID-19 Outbreak|journal=Anesthesiology|volume=132|issue=6|year=2020|pages=1317–1332|issn=0003-3022|doi=10.1097/ALN.0000000000003296}}</ref> The [[COVID-19-associated acute respiratory distress syndrome|CARDS]] Ventilator [[PEEP]] Titration Protocol can be viewed by [https://www.nebraskamed.com/sites/default/files/documents/covid-19/ards-ventilator-peep-titration-protocol.pdf?date=03242020 clicking here].
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| ** ''Types'': Patients with “H type” (high elastance and [[Ventilation/perfusion ratio|V/Q ratio]]) [[CARDS]], may benefit from higher [[PEEP]] and lower [[tidal volume]]s. Patients with “L type” (low lung elastance and [[Ventilation/perfusion ratio|V/Q ratio]]) CARDS may benefit from lower [[PEEP]] and higher [[tidal volumes]].<ref name="MariniGattinoni2020">{{cite journal|last1=Marini|first1=John J.|last2=Gattinoni|first2=Luciano|title=Management of COVID-19 Respiratory Distress|journal=JAMA|volume=323|issue=22|year=2020|pages=2329|issn=0098-7484|doi=10.1001/jama.2020.6825}}</ref> If Type L patient is [[hypercapnic]], volumes greater than 6 ml/kg (up to 8–9 ml/kg) can be helpful.
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| **''Contraindications'' for the use of the [[PEEP]] may include untreated [[pneumothorax]], [[hypotension|very low blood pressure]], elevated [[intracranial pressures|ICP]], and [[pulmonary hypertension]].
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| **''Complications'' of [[PEEP]] may include [[barotrauma]], such as [[pneumothorax]] and/or decreased [[cardiac output]]. [[COVID-19-associated acute respiratory distress syndrome|CARDS]] patients on high [[PEEP]] had no associated complications or increased mortality.<ref name="FanDel Sorbo2017">{{cite journal|last1=Fan|first1=Eddy|last2=Del Sorbo|first2=Lorenzo|last3=Goligher|first3=Ewan C.|last4=Hodgson|first4=Carol L.|last5=Munshi|first5=Laveena|last6=Walkey|first6=Allan J.|last7=Adhikari|first7=Neill K. J.|last8=Amato|first8=Marcelo B. P.|last9=Branson|first9=Richard|last10=Brower|first10=Roy G.|last11=Ferguson|first11=Niall D.|last12=Gajic|first12=Ognjen|last13=Gattinoni|first13=Luciano|last14=Hess|first14=Dean|last15=Mancebo|first15=Jordi|last16=Meade|first16=Maureen O.|last17=McAuley|first17=Daniel F.|last18=Pesenti|first18=Antonio|last19=Ranieri|first19=V. Marco|last20=Rubenfeld|first20=Gordon D.|last21=Rubin|first21=Eileen|last22=Seckel|first22=Maureen|last23=Slutsky|first23=Arthur S.|last24=Talmor|first24=Daniel|last25=Thompson|first25=B. Taylor|last26=Wunsch|first26=Hannah|last27=Uleryk|first27=Elizabeth|last28=Brozek|first28=Jan|last29=Brochard|first29=Laurent J.|title=An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome|journal=American Journal of Respiratory and Critical Care Medicine|volume=195|issue=9|year=2017|pages=1253–1263|issn=1073-449X|doi=10.1164/rccm.201703-0548ST}}</ref>
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| *'''Maintenance Goals''': [[pH]]= 7.25-7.42, [[paO2]] >60/ [[SpO2]]= 88-96%, [[paCO2]]= 40-65/ETCO= 35-60 mmHg ([[permissive hypercapnia]]).
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| ===[[Extracorporeal membrane oxygenation]] (ECMO) ===
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| *Venovenous type of [[Extracorporeal membrane oxygenation|ECMO]] (VV ECMO) drains blood from a large central vein, oxygenates it, and removes [[carbon dioxide]] via the gas-exchange device. The blood is then reinfused. [[Extracorporeal membrane oxygenation|ECMO]] can help avoid ventilator-induced lung injury.
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| * The use of [[Extracorporeal membrane oxygenation|ECMO]] is has been recommended in [[COVID-19]] patients with refractory [[hypoxemia]] or high driving pressure, or [[hypercapnia]]/[[respiratory acidosis]] despite invasive mechanical [[ventilation]] (IMV) and lung-protective measures such as higher [[PEEP]] or [[Mechanical ventilation initial ventilator settings#Proning|prone positioning]]. The strategies can be combined such as in Type H patients, who should be treated as severe [[ARDS]] patients with higher [[PEEP]], if compatible with hemodynamics, [[Mechanical ventilation initial ventilator settings#Proning|prone positioning]] and [[Extracorporeal membrane oxygenation|ECMO]].<ref name="pmid32291463">{{cite journal |vauthors=Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, Camporota L |title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? |journal=Intensive Care Med |volume=46 |issue=6 |pages=1099–1102 |date=June 2020 |pmid=32291463 |pmc=7154064 |doi=10.1007/s00134-020-06033-2 |url=}}</ref><ref name="pmid32645311">{{cite journal |vauthors=Fan E, Beitler JR, Brochard L, Calfee CS, Ferguson ND, Slutsky AS, Brodie D |title=COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted? |journal=Lancet Respir Med |volume= |issue= |pages= |date=July 2020 |pmid=32645311 |pmc=7338016 |doi=10.1016/S2213-2600(20)30304-0 |url=}}</ref><ref name="pmid32506258">{{cite journal |vauthors=Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D |title=Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China |journal=Ann Intensive Care |volume=10 |issue=1 |pages=73 |date=June 2020 |pmid=32506258 |pmc=7275657 |doi=10.1186/s13613-020-00689-1 |url=}}</ref> The [[WHO]] suggested referring [[patients]] with refractory [[hypoxemia]] despite lung-protective [[ventilation]] to the settings with expertise in ECMO.<ref name="urlClinical management of COVID-19">{{cite web |url=https://www.who.int/publications/i/item/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected |title=Clinical management of COVID-19 |format= |work= |accessdate=}}</ref>
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| *It is not known whether [[Extracorporeal membrane oxygenation|ECMO]] reduces [[mortality]] but 6.2% [[patients]] were treated with [[Extracorporeal membrane oxygenation|ECMO]] in Wuhan, China.<ref name="ZengCai2020">{{cite journal|last1=Zeng|first1=Yingchun|last2=Cai|first2=Zhongxiang|last3=Xianyu|first3=Yunyan|last4=Yang|first4=Bing Xiang|last5=Song|first5=Ting|last6=Yan|first6=Qiaoyuan|title=Prognosis when using extracorporeal membrane oxygenation (ECMO) for critically ill COVID-19 patients in China: a retrospective case series|journal=Critical Care|volume=24|issue=1|year=2020|issn=1364-8535|doi=10.1186/s13054-020-2840-8}}</ref><ref name="LiHou2020">{{cite journal|last1=Li|first1=Chenglong|last2=Hou|first2=Xiaotong|last3=Tong|first3=Zhaohui|last4=Qiu|first4=Haibo|last5=Li|first5=Yimin|last6=Li|first6=Ang|title=Extracorporeal membrane oxygenation programs for COVID-19 in China|journal=Critical Care|volume=24|issue=1|year=2020|issn=1364-8535|doi=10.1186/s13054-020-03047-6}}</ref> A definitive recommendation requires additional evidence for or against the use of ECMO in patients with CARDS.<ref name="FanDel Sorbo2017">{{cite journal|last1=Fan|first1=Eddy|last2=Del Sorbo|first2=Lorenzo|last3=Goligher|first3=Ewan C.|last4=Hodgson|first4=Carol L.|last5=Munshi|first5=Laveena|last6=Walkey|first6=Allan J.|last7=Adhikari|first7=Neill K. J.|last8=Amato|first8=Marcelo B. P.|last9=Branson|first9=Richard|last10=Brower|first10=Roy G.|last11=Ferguson|first11=Niall D.|last12=Gajic|first12=Ognjen|last13=Gattinoni|first13=Luciano|last14=Hess|first14=Dean|last15=Mancebo|first15=Jordi|last16=Meade|first16=Maureen O.|last17=McAuley|first17=Daniel F.|last18=Pesenti|first18=Antonio|last19=Ranieri|first19=V. Marco|last20=Rubenfeld|first20=Gordon D.|last21=Rubin|first21=Eileen|last22=Seckel|first22=Maureen|last23=Slutsky|first23=Arthur S.|last24=Talmor|first24=Daniel|last25=Thompson|first25=B. Taylor|last26=Wunsch|first26=Hannah|last27=Uleryk|first27=Elizabeth|last28=Brozek|first28=Jan|last29=Brochard|first29=Laurent J.|title=An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome|journal=American Journal of Respiratory and Critical Care Medicine|volume=195|issue=9|year=2017|pages=1253–1263|issn=1073-449X|doi=10.1164/rccm.201703-0548ST}}</ref>
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| ==Stratagies to improve oxygenation==
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| ====[[Mechanical ventilation initial ventilator settings#Proning|Prone position ventilation]]====
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| *[[Mechanical ventilation initial ventilator settings#Proning|Prone positioning]] is thought to improve oxygenation by improving [[Ventilation-perfusion mismatch|ventilation/perfusion (V/Q) mismatching]] via reduced shunting of blood through under-ventilated lung tissue.
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| *[[Prone position]] ventilation in [[ARDS]] patients with acute hypoxemic [[respiratory failure]] and spontaneous or assisted breathing reduces the [[mortality]] by 28 and 90-days.<ref name="pmid29576824">{{cite journal |vauthors=Xie H, Zhou ZG, Jin W, Yuan CB, Du J, Lu J, Wang RL |title=Ventilator management for acute respiratory distress syndrome associated with avian influenza A (H7N9) virus infection: A case series |journal=World J Emerg Med |volume=9 |issue=2 |pages=118–124 |date=2018 |pmid=29576824 |pmc=5847497 |doi=10.5847/wjem.j.1920-8642.2018.02.006 |url=}}</ref>
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| *The strategy was widely used in [[COVID-19]] patients in Wuhan, China.<ref name="MengQiu2020">{{cite journal|last1=Meng|first1=Lingzhong|last2=Qiu|first2=Haibo|last3=Wan|first3=Li|last4=Ai|first4=Yuhang|last5=Xue|first5=Zhanggang|last6=Guo|first6=Qulian|last7=Deshpande|first7=Ranjit|last8=Zhang|first8=Lina|last9=Meng|first9=Jie|last10=Tong|first10=Chuanyao|last11=Liu|first11=Hong|last12=Xiong|first12=Lize|title=Intubation and Ventilation amid the COVID-19 Outbreak|journal=Anesthesiology|volume=132|issue=6|year=2020|pages=1317–1332|issn=0003-3022|doi=10.1097/ALN.0000000000003296}}</ref>
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| *[[Mechanical ventilation initial ventilator settings#Proning|Prone position]] is an early strategy rather than a desperate rescue therapy.<ref name="TeliasKatira2020">{{cite journal|last1=Telias|first1=Irene|last2=Katira|first2=Bhushan H.|last3=Brochard|first3=Laurent|title=Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?|journal=JAMA|volume=323|issue=22|year=2020|pages=2265|issn=0098-7484|doi=10.1001/jama.2020.8539}}</ref> A study by Lin Ding et al. suggests that the early application of prone ventilation with HFNC and NIV, especially in [[COVID-19]] patients with moderate [[ARDS]], can help avoid [[intubation]].<ref name="pmid32000806">{{cite journal |vauthors=Ding L, Wang L, Ma W, He H |title=Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study |journal=Crit Care |volume=24 |issue=1 |pages=28 |date=January 2020 |pmid=32000806 |pmc=6993481 |doi=10.1186/s13054-020-2738-5 |url=}}</ref> Prone position,with other adjunct therapies may probably be used for critically ill patients even during [[Extracorporeal membrane oxygenation|ECMO]].<ref name="pmid32506258">{{cite journal |vauthors=Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D |title=Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China |journal=Ann Intensive Care |volume=10 |issue=1 |pages=73 |date=June 2020 |pmid=32506258 |pmc=7275657 |doi=10.1186/s13613-020-00689-1 |url=}}</ref>
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| * [[Mechanical ventilation initial ventilator settings#Proning|Prone position]] for awake patients during spontaneous or assisted breathing during [[Positive airway pressure|NIPPV]] or HFNC with mild-moderate [[ARDS]] was associated with an improved oxygenation.<ref name="SartiniTresoldi2020">{{cite journal|last1=Sartini|first1=Chiara|last2=Tresoldi|first2=Moreno|last3=Scarpellini|first3=Paolo|last4=Tettamanti|first4=Andrea|last5=Carcò|first5=Francesco|last6=Landoni|first6=Giovanni|last7=Zangrillo|first7=Alberto|title=Respiratory Parameters in Patients With COVID-19 After Using Noninvasive Ventilation in the Prone Position Outside the Intensive Care Unit|journal=JAMA|volume=323|issue=22|year=2020|pages=2338|issn=0098-7484|doi=10.1001/jama.2020.7861}}</ref> In addition, patients with an Spo2 of 95% or greater after an hour of the [[Mechanical ventilation initial ventilator settings#Proning|prone position]] had a lower rate of [[intubation]].<ref name="ThompsonRanard2020">{{cite journal|last1=Thompson|first1=Alison E.|last2=Ranard|first2=Benjamin L.|last3=Wei|first3=Ying|last4=Jelic|first4=Sanja|title=Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure|journal=JAMA Internal Medicine|year=2020|issn=2168-6106|doi=10.1001/jamainternmed.2020.3030}}</ref> To answer the question about the effectiveness, two [[Randomized controlled trial|RCTs]] are in progress [https://clinicaltrials.gov/ct2/show/NCT04347941 NCT04347941] and [https://clinicaltrials.gov/ct2/show/NCT04350723 NCT04350723].<ref name="TeliasKatira2020">{{cite journal|last1=Telias|first1=Irene|last2=Katira|first2=Bhushan H.|last3=Brochard|first3=Laurent|title=Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?|journal=JAMA|volume=323|issue=22|year=2020|pages=2265|issn=0098-7484|doi=10.1001/jama.2020.8539}}</ref>
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| *The American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice and SSC guidelines strongly recommend (moderate evidence) [[Mechanical ventilation initial ventilator settings#Proning|Prone positioning]] for more than 12 hours/day in patients with severe [[ARDS]].<ref name="FanDel Sorbo2017">{{cite journal|last1=Fan|first1=Eddy|last2=Del Sorbo|first2=Lorenzo|last3=Goligher|first3=Ewan C.|last4=Hodgson|first4=Carol L.|last5=Munshi|first5=Laveena|last6=Walkey|first6=Allan J.|last7=Adhikari|first7=Neill K. J.|last8=Amato|first8=Marcelo B. P.|last9=Branson|first9=Richard|last10=Brower|first10=Roy G.|last11=Ferguson|first11=Niall D.|last12=Gajic|first12=Ognjen|last13=Gattinoni|first13=Luciano|last14=Hess|first14=Dean|last15=Mancebo|first15=Jordi|last16=Meade|first16=Maureen O.|last17=McAuley|first17=Daniel F.|last18=Pesenti|first18=Antonio|last19=Ranieri|first19=V. Marco|last20=Rubenfeld|first20=Gordon D.|last21=Rubin|first21=Eileen|last22=Seckel|first22=Maureen|last23=Slutsky|first23=Arthur S.|last24=Talmor|first24=Daniel|last25=Thompson|first25=B. Taylor|last26=Wunsch|first26=Hannah|last27=Uleryk|first27=Elizabeth|last28=Brozek|first28=Jan|last29=Brochard|first29=Laurent J.|title=An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome|journal=American Journal of Respiratory and Critical Care Medicine|volume=195|issue=9|year=2017|pages=1253–1263|issn=1073-449X|doi=10.1164/rccm.201703-0548ST}}</ref><ref name="RhodesEvans2017">{{cite journal|last1=Rhodes|first1=Andrew|last2=Evans|first2=Laura E.|last3=Alhazzani|first3=Waleed|last4=Levy|first4=Mitchell M.|last5=Antonelli|first5=Massimo|last6=Ferrer|first6=Ricard|last7=Kumar|first7=Anand|last8=Sevransky|first8=Jonathan E.|last9=Sprung|first9=Charles L.|last10=Nunnally|first10=Mark E.|last11=Rochwerg|first11=Bram|last12=Rubenfeld|first12=Gordon D.|last13=Angus|first13=Derek C.|last14=Annane|first14=Djillali|last15=Beale|first15=Richard J.|last16=Bellinghan|first16=Geoffrey J.|last17=Bernard|first17=Gordon R.|last18=Chiche|first18=Jean-Daniel|last19=Coopersmith|first19=Craig|last20=De Backer|first20=Daniel P.|last21=French|first21=Craig J.|last22=Fujishima|first22=Seitaro|last23=Gerlach|first23=Herwig|last24=Hidalgo|first24=Jorge Luis|last25=Hollenberg|first25=Steven M.|last26=Jones|first26=Alan E.|last27=Karnad|first27=Dilip R.|last28=Kleinpell|first28=Ruth M.|last29=Koh|first29=Younsuk|last30=Lisboa|first30=Thiago Costa|last31=Machado|first31=Flavia R.|last32=Marini|first32=John J.|last33=Marshall|first33=John C.|last34=Mazuski|first34=John E.|last35=McIntyre|first35=Lauralyn A.|last36=McLean|first36=Anthony S.|last37=Mehta|first37=Sangeeta|last38=Moreno|first38=Rui P.|last39=Myburgh|first39=John|last40=Navalesi|first40=Paolo|last41=Nishida|first41=Osamu|last42=Osborn|first42=Tiffany M.|last43=Perner|first43=Anders|last44=Plunkett|first44=Colleen M.|last45=Ranieri|first45=Marco|last46=Schorr|first46=Christa A.|last47=Seckel|first47=Maureen A.|last48=Seymour|first48=Christopher W.|last49=Shieh|first49=Lisa|last50=Shukri|first50=Khalid A.|last51=Simpson|first51=Steven Q.|last52=Singer|first52=Mervyn|last53=Thompson|first53=B. Taylor|last54=Townsend|first54=Sean R.|last55=Van der Poll|first55=Thomas|last56=Vincent|first56=Jean-Louis|last57=Wiersinga|first57=W. Joost|last58=Zimmerman|first58=Janice L.|last59=Dellinger|first59=R. Phillip|title=Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016|journal=Intensive Care Medicine|volume=43|issue=3|year=2017|pages=304–377|issn=0342-4642|doi=10.1007/s00134-017-4683-6}}</ref>
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| {{#ev:youtube|https://www.youtube.com/watch?v=lcBPaHQUvXY}}
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| *In [[mechanical ventilation|mechanically ventilated]] patients with [[PaO2/FiO2]] <150, [[Mechanical ventilation initial ventilator settings#Proning|prone positioning]] can be used.<ref name="pmid32645311">{{cite journal |vauthors=Fan E, Beitler JR, Brochard L, Calfee CS, Ferguson ND, Slutsky AS, Brodie D |title=COVID-19-associated acute respiratory distress syndrome: is a different approach to management warranted? |journal=Lancet Respir Med |volume= |issue= |pages= |date=July 2020 |pmid=32645311 |pmc=7338016 |doi=10.1016/S2213-2600(20)30304-0 |url=}}</ref>
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| ===Special considerationss===
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| *'''Lung recruitment maneuvers'''<ref name="MengQiu2020">{{cite journal|last1=Meng|first1=Lingzhong|last2=Qiu|first2=Haibo|last3=Wan|first3=Li|last4=Ai|first4=Yuhang|last5=Xue|first5=Zhanggang|last6=Guo|first6=Qulian|last7=Deshpande|first7=Ranjit|last8=Zhang|first8=Lina|last9=Meng|first9=Jie|last10=Tong|first10=Chuanyao|last11=Liu|first11=Hong|last12=Xiong|first12=Lize|title=Intubation and Ventilation amid the COVID-19 Outbreak|journal=Anesthesiology|volume=132|issue=6|year=2020|pages=1317–1332|issn=0003-3022|doi=10.1097/ALN.0000000000003296}}</ref><ref name="CuiCao2020">{{cite journal|last1=Cui|first1=Yu|last2=Cao|first2=Rong|last3=Wang|first3=Yu|last4=Li|first4=Gen|title=Lung Recruitment Maneuvers for ARDS Patients: A Systematic Review and Meta-Analysis|journal=Respiration|volume=99|issue=3|year=2020|pages=264–276|issn=0025-7931|doi=10.1159/000501045}}</ref><ref name="pmid27855477">{{cite journal |vauthors=Hodgson C, Goligher EC, Young ME, Keating JL, Holland AE, Romero L, Bradley SJ, Tuxen D |title=Recruitment manoeuvres for adults with acute respiratory distress syndrome receiving mechanical ventilation |journal=Cochrane Database Syst Rev |volume=11 |issue= |pages=CD006667 |date=November 2016 |pmid=27855477 |pmc=6464835 |doi=10.1002/14651858.CD006667.pub3 |url=}}</ref>: Lung recruitment maneuver is the application of very high (up to 40 cm H2O) [[positive airway pressure]] during mechanical [[ventilation]]. It opens the collapsed [[alveoli]], decreasing [[Ventilation-perfusion mismatch|ventilation/perfusion (V/Q) mismatching]] thus improving the gas exchange. For [[ARDS]] patients, the maneuvers may help improve oxygenation and decrease the length of hospital stay with no positive effect on reducing [[mortality]]. The decision varies on a case by case basis depending upon lung condition and [[patient]] hemodynamics. On the trouble side, the maneuver may generate aerosols. High-quality evidence is lacking to support the use in [[ARDS]] patients.
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| *'''[[Paralytics]]''':<ref name="pmid32360979">{{cite journal |vauthors=Payen JF, Chanques G, Futier E, Velly L, Jaber S, Constantin JM |title=Sedation for critically ill patients with COVID-19: Which specificities? One size does not fit all |journal=Anaesth Crit Care Pain Med |volume=39 |issue=3 |pages=341–343 |date=June 2020 |pmid=32360979 |pmc=7189860 |doi=10.1016/j.accpm.2020.04.010 |url=}}</ref><ref name="urlCoronavirus (COVID-19) Update: Daily Roundup May 5, 2020 | FDA">{{cite web |url=https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-daily-roundup-may-5-2020 |title=Coronavirus (COVID-19) Update: Daily Roundup May 5, 2020 | FDA |format= |work= |accessdate=}}</ref> The [[paralytics]] may be used with [[analgesic]]s ([[fentanyl]], [[hydromorphone]]) and [[sedative]]s ([[benzodiazepines]], [[propofol]]). In [[COVID-19-associated acute respiratory distress syndrome|CARDS]] patients, Richmond Agitation Sedation Scale (RASS) score of (+2 to +4) even after optimal ventilatoy settings may indicate the use of deep [[sedation]] with [[paralytics]]. If used, short-term (24– 48 hours) and intermittent muscle relaxation is recommended. Prone position ventilation may also require muscle relaxation along with sedation. [[Paralytics]] are not recommended in an unless [[Hypoxemia laboratory findings|PaO2/FiO2]] < 150 mmHg. The paralytics that are being used in [[COVID-19-associated acute respiratory distress syndrome|CARDS]]patients include: [[Suxamethonium chloride|Succinylcholine chloride injection]] USP 200 mg/10 mL and [[Cisatracurium|cisatracurium besylate injection]] USP 20 mg/10 mL.
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| '''Aerosol Generation Risk Factors and Protective Measures'''<br>
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| Concerns have been raised for a possible risk for transmission of [[COVID-19]] to health care personnel due to aerosol transmission.<ref name="pmid32442035">{{cite journal |vauthors=Schünemann HJ, Khabsa J, Solo K, Khamis AM, Brignardello-Petersen R, El-Harakeh A, Darzi A, Hajizadeh A, Bognanni A, Bak A, Izcovich A, Cuello-Garcia CA, Chen C, Borowiack E, Chamseddine F, Schünemann F, Morgano GP, Muti-Schünemann GEU, Chen G, Zhao H, Neumann I, Brozek J, Schmidt J, Hneiny L, Harrison L, Reinap M, Junek M, Santesso N, El-Khoury R, Thomas R, Nieuwlaat R, Stalteri R, Yaacoub S, Lotfi T, Baldeh T, Piggott T, Zhang Y, Saad Z, Rochwerg B, Perri D, Fan E, Stehling F, Akl IB, Loeb M, Garner P, Aston S, Alhazzani W, Szczeklik W, Chu DK, Akl EA |title=Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19: A Living Systematic Review of Multiple Streams of Evidence |journal=Ann. Intern. Med. |volume= |issue= |pages= |date=May 2020 |pmid=32442035 |pmc=7281716 |doi=10.7326/M20-2306 |url=}}</ref> With the judicious use of the standard precautions and protective measures, the results for the mentioned interventions have been promising.
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| <br />
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| {| class="wikitable"
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| |+
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| !Source of aerosol generation
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| !Protective Measures
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| |Coughing
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| * Utilize full [[Personal protective equipment]] (PPE) prior to entering intubation room
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| * Minimize period between removal of patient's [[Personal protective equipment|PPE]] and application of face mask with viral filter
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| * Ensure sealing of face mask
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| * USe of local [[lidocaine]] via [[ETT]] or during procedures such as [[bronchoscopy]] and [[opoids]] in minimum dose
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| |-
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| |Face Mask Seal Leak
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| * Optimum fitting of the face mask
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| * Vice (V-E) grip
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| * Use manual ventilation Ambu bag
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| * ETO2 monitoring
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| |-
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| |Non-Invasive ventilation, [[bronchoscopy]], [[CPR]]<br> [[extubation]], and manual [[ventilation]]
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| *[[WHO]] recommends the use of [[PPE]] that includes respirators, eye protection, gloves and gowns; aprons if gowns are not fluid resistant.<ref name="urlapps.who.int">{{cite web |url=https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf |title=apps.who.int |format= |work= |accessdate=}}</ref>
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| *In addition to regular precautions such as the use of [[PPE]] followed during [[COVID-19]] pandemic following precautions as advised by [[CDC]] to prevent [[Airborne transmission|airborne]] transmission should be taken:<ref name="urlTransmission-Based Precautions | Basics | Infection Control | CDC”">{{cite web |url=https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html |title=Transmission-Based Precautions | Basics | Infection Control | CDC” |format= |work= |accessdate=}}</ref>
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| **[[Airborne transmission|Airborne infection]] isolation room (AIIR)
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| **Restricting susceptible healthcare personnel
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| **Limiting transport and movement of the [[patient]]
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| **Use of fit-tested [[Occupational safety and health|NIOSH]]-approved N95 or higher level respirator for healthcare personnel.
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| **The staff who are expected to help during the procedure should be informed and ready with [[PPE]]s.
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| *If possible, use disposable [[bronchoscope]] or cleaning the suction channels with the cleaning solutions used for highly [[infectious]] materials.
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| |[[Intubation]]
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| *Above mentioned precautions such as the use of [[PPE]] and AIIR with minimal personnel in the room should be followed.
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| *Chest [[auscultation]] after [[intubation]] is not recommended due to aerosol transmission of the [[SARS-CoV-2|severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)]] virus.
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| *[[Oxygen saturation|Spo2]], chest movements, [[capnography]], fogging inside of the [[endotracheal tube]], and the color of the patient’s skin and [[mucous membrane]] can be used to confirm a successful [[intubation]].<ref name="MengQiu2020">{{cite journal|last1=Meng|first1=Lingzhong|last2=Qiu|first2=Haibo|last3=Wan|first3=Li|last4=Ai|first4=Yuhang|last5=Xue|first5=Zhanggang|last6=Guo|first6=Qulian|last7=Deshpande|first7=Ranjit|last8=Zhang|first8=Lina|last9=Meng|first9=Jie|last10=Tong|first10=Chuanyao|last11=Liu|first11=Hong|last12=Xiong|first12=Lize|title=Intubation and Ventilation amid the COVID-19 Outbreak|journal=Anesthesiology|volume=132|issue=6|year=2020|pages=1317–1332|issn=0003-3022|doi=10.1097/ALN.0000000000003296}}</ref>
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| |[[Tracheostomy]]
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| *Above mentioned precautions such as the use of [[PPE]] and AIIR with minimal personnel in the room should be followed.
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| *During the procedure, minimal use of [[diathermy]], and maintenance of bloodless fields should be ensured.
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| *Post-procedure, reduce the frequency of changing an inner cannula and cuff pressure checks to a possible minimum for the patient.
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| *Post [[tracheostomy]], humidification can be provided via heat and moisture exchange filter or a water-based humidification such as [[hypertonic saline]] [[nebulizers]].
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| *Patients should use facemasks and [[tracheostomy]] shields during trials of [[tracheostomy]] cuff deflation.<ref name="McGrathBrenner2020">{{cite journal|last1=McGrath|first1=Brendan A|last2=Brenner|first2=Michael J|last3=Warrillow|first3=Stephen J|last4=Pandian|first4=Vinciya|last5=Arora|first5=Asit|last6=Cameron|first6=Tanis S|last7=Añon|first7=José Manuel|last8=Hernández Martínez|first8=Gonzalo|last9=Truog|first9=Robert D|last10=Block|first10=Susan D|last11=Lui|first11=Grace C Y|last12=McDonald|first12=Christine|last13=Rassekh|first13=Christopher H|last14=Atkins|first14=Joshua|last15=Qiang|first15=Li|last16=Vergez|first16=Sébastien|last17=Dulguerov|first17=Pavel|last18=Zenk|first18=Johannes|last19=Antonelli|first19=Massimo|last20=Pelosi|first20=Paolo|last21=Walsh|first21=Brian K|last22=Ward|first22=Erin|last23=Shang|first23=You|last24=Gasparini|first24=Stefano|last25=Donati|first25=Abele|last26=Singer|first26=Mervyn|last27=Openshaw|first27=Peter J M|last28=Tolley|first28=Neil|last29=Markel|first29=Howard|last30=Feller-Kopman|first30=David J|title=Tracheostomy in the COVID-19 era: global and multidisciplinary guidance|journal=The Lancet Respiratory Medicine|volume=8|issue=7|year=2020|pages=717–725|issn=22132600|doi=10.1016/S2213-2600(20)30230-7}}</ref>
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| |}
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| <br />
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|
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|
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| ==Bronchoscopy==
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| *Very limited studies are available on the use of [[bronchoscopy]] in [[COVID-19]] patients due to a very high risk of aerosol transmission. [[Bronchopy]] as a well-tolerated therapeutic intervention, performed in [[mechanical ventilation|mechanically ventilated]] patients with [[COVID-19]] have been reported in an observational study. [[FiO2]] was increased to [[Oxygen saturation|SpO2]] of 95%–98% before the intervention. Precautions such as the use of a negative-pressure room, [[PPE]], and duration of the procedure never more than 10 minutes were observed. The study showed that [[patients]] can benefit from therapeutic [[bronchoscopy]] for the removal of thick hypersecretions in the airway (most common complication observed). Guided mini-[[Bronchoalveolar lavage|BAL]] can also help confirm the clinical suspicion of [[superinfection]]. <ref name="pmid32412787">{{cite journal |vauthors=Torrego A, Pajares V, Fernández-Arias C, Vera P, Mancebo J |title=Bronchoscopy in Patients with COVID-19 with Invasive Mechanical Ventilation: A Single-Center Experience |journal=Am. J. Respir. Crit. Care Med. |volume=202 |issue=2 |pages=284–287 |date=July 2020 |pmid=32412787 |pmc=7365381 |doi=10.1164/rccm.202004-0945LE |url=}}</ref>
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|
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| ==Tracheostomy==
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| *Standard decision making for [[tracheostomy]] in a [[COVID]] patient is practiced. But owing to the potential of aerosol spread of the [[infection]] certain considerations should be kept in mind, such as the safety of other the patient's family, other [[patient]]s, healthcare personnel, and the resources available.<ref name="ZhangHuang2020">{{cite journal|last1=Zhang|first1=Xiaomeng|last2=Huang|first2=Qiling|last3=Niu|first3=Xun|last4=Zhou|first4=Tao|last5=Xie|first5=Zhen|last6=Zhong|first6=Yi|last7=Xiao|first7=Hongjun|title=
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| Safe and effective management of tracheostomy in
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| COVID
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| ‐19 patients
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| |journal=Head & Neck|volume=42|issue=7|year=2020|pages=1374–1381|issn=1043-3074|doi=10.1002/hed.26261}}</ref>
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| *[[Tracheostomy]] should be delayed until at least the 10th day of mechanical [[ventilation]]. It should be considered only when the [[patient]] is clinically improving. The decision of extubation should be limited to the [[patient]]s who have a high chance of success.<ref name="McGrathBrenner2020">{{cite journal|last1=McGrath|first1=Brendan A|last2=Brenner|first2=Michael J|last3=Warrillow|first3=Stephen J|last4=Pandian|first4=Vinciya|last5=Arora|first5=Asit|last6=Cameron|first6=Tanis S|last7=Añon|first7=José Manuel|last8=Hernández Martínez|first8=Gonzalo|last9=Truog|first9=Robert D|last10=Block|first10=Susan D|last11=Lui|first11=Grace C Y|last12=McDonald|first12=Christine|last13=Rassekh|first13=Christopher H|last14=Atkins|first14=Joshua|last15=Qiang|first15=Li|last16=Vergez|first16=Sébastien|last17=Dulguerov|first17=Pavel|last18=Zenk|first18=Johannes|last19=Antonelli|first19=Massimo|last20=Pelosi|first20=Paolo|last21=Walsh|first21=Brian K|last22=Ward|first22=Erin|last23=Shang|first23=You|last24=Gasparini|first24=Stefano|last25=Donati|first25=Abele|last26=Singer|first26=Mervyn|last27=Openshaw|first27=Peter J M|last28=Tolley|first28=Neil|last29=Markel|first29=Howard|last30=Feller-Kopman|first30=David J|title=Tracheostomy in the COVID-19 era: global and multidisciplinary guidance|journal=The Lancet Respiratory Medicine|volume=8|issue=7|year=2020|pages=717–725|issn=22132600|doi=10.1016/S2213-2600(20)30230-7}}</ref>
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|
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| ==[[Cardiopulmonary resuscitation]] (CPR)==
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| [[American Heart Association]]'s (AHA) interim ''BLS Healthcare Provider Adult Cardiac Arrest Algorithm for Suspected or Confirmed COVID-19 Patients'' can be accessed by [https://cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/english/algorithmbls_adult_cacovid_200406.pdf?la=en clicking here].<ref name="urlCoronavirus (COVID-19) Resources for CPR Training | American Heart Association CPR & First Aid">{{cite web |url=https://cpr.heart.org/en/resources/coronavirus-covid19-resources-for-cpr-training |title=Coronavirus (COVID-19) Resources for CPR Training | American Heart Association CPR & First Aid |format= |work= |accessdate=}}</ref>
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| ==References==
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| {{Reflist|2}}
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