Chest
Volume 158, Issue 5, November 2020, Pages 1992-2002
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Critical Care: How I Do It
High-Flow, Noninvasive Ventilation and Awake (Nonintubation) Proning in Patients With Coronavirus Disease 2019 With Respiratory Failure

https://doi.org/10.1016/j.chest.2020.07.013Get rights and content

The coronavirus disease 2019 pandemic will be remembered for the rapidity with which it spread, the morbidity and mortality associated with it, and the paucity of evidence-based management guidelines. One of the major concerns of hospitals was to limit spread of infection to health-care workers. Because the virus is spread mainly by respiratory droplets and aerosolized particles, procedures that may potentially disperse viral particles, the so-called “aerosol-generating procedures” were avoided whenever possible. Included in this category were noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and awake (nonintubated) proning. Accordingly, at many health-care facilities, patients who had increasing oxygen requirements were emergently intubated and mechanically ventilated to avoid exposure to aerosol-generating procedures. With experience, physicians realized that mortality of invasively ventilated patients was high and it was not easy to extubate many of these patients. This raised the concern that HFNC and NIV were being underutilized to avoid intubation and to facilitate extubation. In this article, we attempt to separate fact from fiction and perception from reality pertaining to the aerosol dispersion with NIV, HFNC, and awake proning. We describe precautions that hospitals and health-care providers must take to mitigate risks with these devices. Finally, we take a practical approach in describing how we use the three techniques, including the common indications, contraindications, and practical aspects of application.

Key Words

awake proning
coronavirus disease 2019
COVID-19
helmet mask
high-flow nasal cannula
noninvasive ventilation

Abbreviations

AGP
aerosol-generating procedure
COVID-19
coronavirus disease 2019
HEPA
high-energy particulate accumulator
HFNC
high-flow nasal cannula
NIV
noninvasive ventilation
NRB
nonrebreather
PEEP
positive end-expiratory pressure
PPE
personal protective equipment
ROX
ratio of oxygen saturation as measured by pulse oximetry/Fio2 to respiratory rate
SARS-CoV-2
severe acute respiratory syndrome coronavirus 2
SO
standard oxygen

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