King's College London

Research portal

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

Research output: Contribution to journalArticlepeer-review

Prashant Nasa, Elie Azoulay, Ashish K Khanna, Ravi Jain, Sachin Gupta, Yash Javeri, Deven Juneja, Pradeep Rangappa, Krishnaswamy Sundararajan, Waleed Alhazzani, Massimo Antonelli, Yaseen M Arabi, Jan Bakker, Laurent J Brochard, Adam M Deane, Bin Du, Sharon Einav, Andrés Esteban, Ognjen Gajic, Samuel M Galvagno & 29 more Claude Guérin, Samir Jaber, Gopi C Khilnani, Younsuck Koh, Jean-Baptiste Lascarrou, Flavia R Machado, Manu L N G Malbrain, Jordi Mancebo, Michael T McCurdy, Brendan A McGrath, Sangeeta Mehta, Armand Mekontso-Dessap, Mervyn Mer, Michael Nurok, Pauline K Park, Paolo Pelosi, John V Peter, Jason Phua, David V Pilcher, Lise Piquilloud, Peter Schellongowski, Marcus J Schultz, Manu Shankar-Hari, Suveer Singh, Massimiliano Sorbello, Ravindranath Tiruvoipati, Andrew A Udy, Tobias Welte, Sheila N Myatra

Original languageEnglish
Article number106
Pages (from-to)106
Number of pages1
JournalCritical care (London, England)
Issue number1
Published16 Mar 2021

Bibliographical note

Funding Information: EA reports having taken professional fees for lectures from Gilead, Pfizer, Baxter and Alexion. His research group has been supported by Ablynx, Fisher & Paykel, Jazz Pharma and MSD, all outside the scope of submitted work. AKK reports institutional funding for 2 trials, a randomized Clinical Trial of CLR2.0 Hemofiltration Treatment (C2Rx) in Severe or Critically Ill Adults With COVID-19 Infection ( Identifier: NCT04537975) and Blood Volume Assessment in COVID-19 ICU Patients—BVAC19 ( Identifier: NCT04517695). He is site PI for SCCM Discovery Network Viral Infection and Respiratory Illness Universal Study [VIRUS]: COVID-19 Registry ( Identifier: NCT04323787) and is a member of American Society of Anesthesiologists (ASA) COVID-19 task force. AKK is a key opinion leader and consults for Medtronic, Edwards Lifesciences, Philips North America and Zoll Medical, is on the advisory board for Potrero Medical and Retia Medical and receives compensation for his position for the chair of the trial steering committee for the SILtuximab in Viral ARds (SILVAR) Study (SILVAR) ( Identifier: NCT04616586) all outside the scope of the submitted work. He is also funded with a Clinical and Translational Science Institute (CTSI) NIH/NCTAS KL2 TR001421 award for a trial on continuous postoperative hemodynamic and saturation monitoring. AKK is a founding member of BrainX LLC, a collaborative platform for research and development of artificial intelligence technology in critical care and perioperative medicine. YJ is a member of CII Medical Task Force, India and a member of the steering committee for a Phase 3, Prospective, Randomized, Open Label, Comparative, Clinical Study To Evaluate Efficacy And Safety Of Ulinastatin Plus Standard-Of-Care Compared To Standard-Of-Care In Treatment Of Acute Respiratory Distress Syndrome (ARDS) In Hospitalized COVID-19 Infection Patients. WAH is a co-chair of COVID-19 surviving sepsis campaign guidelines. MA is a panel member of Surviving Sepsis Campaign. YMA is a co-investigator on COVI-PRONE trial ( Identifier: NCT04350723) and is a panel member of Surviving Sepsis Campaign CPG. LJB reports grants from Medtronic Covidien, grants and non-financial support from Fisher Paykel, non-financial support from Air Liquide, Sentec, Philips and General Electric (patent), all outside the scope of submitted work. SJ reports receiving consulting fees from Drager, Medtronic, Baxter, Fresenius and Fisher & Paykel, all outside the scope of submitted work. JBL received lectures fees from BD and Zoll (outside the scope: cooling devices), all outside the scope of submitted work. MLNGM is a co-founder, past-President and current Treasurer of WSACS (The Abdominal Compartment Society, ). MLNGM is member of the medical advisory Board of Pulsion Medical Systems (part of Getinge group) and Serenno Medical, consults for Baxter, BD, BBraun, ConvaTec, Acelity, Spiegelberg and Holtech Medical and is co-founder of the International Fluid Academy (IFA) which is integrated within the not-for-profit charitable organization iMERiT (International Medical Education and Research Initiative) under the Belgian law, all outside the scope of submitted work. JM reports personal fees (last three years) from Faron, Medtronic and Janssen, all outside the scope of submitted work. AM reports grants from Fischer Paykel, Baxter and Ferring, and personal fees from Air Liquide, Amomed and Addmedica, all outside the scope of submitted work. MN is an advisor with Avant-Grande Health Inc and receive stock option for this role, all outside the submitted work. PKP reports grant funding from NIH for Operation Warp Speed COVID clinical trials and from DoD, Eli Lilly, Bristol Myers Squibb, ATOX Bio, Marcus Foundation, all outside the scope of submitted work. She is a council member of Society of Critical Care Medicine. LP reports lectures fees from Hamilton and Getinge and consultant fees from Löwenstein, all outside the scope of submitted work. MSH reports funding and support by the National Institute for Health Research Clinician Scientist Award (CS-2016–16-011). Also, the views expressed in this publication are those of the author and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. MS reports paid consultancy, lecture grants: Teleflex Medical (Athlone, Ireland); Verathon Medical (Bothell, USA); travel grants, lecture grants: MSD Italy, MSD USA; Baxter Italy, all outside the scope of submitted work. AAU reports membership of Management Committee, SPRINT-SARI Australia. TW reports research Grants from DFG, BMBF, EU, WHO, fees for lectures from AstraZeneca, Basilea, Biotest, Bayer, Boehringer, GSK, MSD, Novartis, Pfizer, Roche, Sanofi Aventis, all outside the scope of submitted work. He is a member on advisory Board of AstraZeneca, Basilea, Biotest, Bayer, Boehringer, GSK, Janssens, Novartis, Pfizer, Roche, Sanofi Aventis. SNM reports membership of COVID-19 Surviving Sepsis Campaign (SSC) guidelines committee and being on the steering committee of the COVID Steroid 2 Trial ( Identifier: NCT04509973) and the HydrOxychloroquine Prophylaxis Evaluation (HOPE) Trial (CTRI registration No. CTRI/2020/05/025067). All other authors declare no competing interest. Publisher Copyright: © 2021, The Author(s). Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

King's Authors


BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION: The study was registered with Clinical Identifier: NCT04534569.

View graph of relations

© 2020 King's College London | Strand | London WC2R 2LS | England | United Kingdom | Tel +44 (0)20 7836 5454