NHS on NIV for management of Hypoxaemia in COVID-19

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NHS on NIV for management of Hypoxaemia in COVID-19

Salient Points

This guidance from the NHS is about the preferred methods of Ventilation for COVID-19 patients with respiratory distress.

It elaborates on the following:

  • Oxygenation target: SpO2 94-96% in previously well, or 88-92% in patients with previous chronic respiratory failure
  • Settings suggested for NIV: PS -8-10 cmH2O, PEEP 5-10 cm. FiO2- 60%. All PPE precautions to be followed.
  • Adult Escalation Plan in 3 gradually escalating categories
    • Category Green
    • Category Yellow
    • Category Red

Detailed Summary

CPAP is the preferred form of NIV support in management of hypoxaemia with an initial setting of 10cmH2O and 60% Oxygen. It does not replace IMV but early application by ICUs may provide a bridge to IMV.

Patients that respond to the CPAP must be assessed regularly every 30-60minutes. If the patient declines further, seek intubation.

Oxygenation target

  • SpO2 – 94% – 96% or 88% – 92% for patients with chronic or acute on chronic type 2 respiratory failure.

Use of NIV should be reserved for those patients with hypercapnic acute on chronic ventilatory failure.

Suggested NIV settings

  1. PS – 8-10 cmH2O
  2. PEEP – 5-10cmH2O
  3. Oxygen – 60%
  • Monitoring should focus on
  1. RR
  2. Work of breathing
  3. SpO2
  4. HR
  • Use of HFNO is not advocated in COVID-19 patients – due to lack of efficacy, O2 use and infection spread.

Note

  1. There is a risk of exhaled droplet dispersion from all three non invasive respiratory support modalities, but is likely to be low.
  2. Respiratory PPE should be worn in accordance with PHE guidance.

Adult Escalation Plan following initial assessment and treatment for COVID-19 patients

  1. Category Green
    1. Clinical Status – RR >= 20bpm with SpO2 =< 94%
    2. Action – Administer O2 < 40% by Face Mask, if SpO2 rises to > 94% observe and monitor
  1. Category Yellow
    1. Clinical Status – RR >= 20bpm with SpO2 =< 94% on FiO2 >= 40%
    2. Action – Start 15L/min O2 via non rebreathe mask
      1. If oriented and able to tolerate well fitted non vented face mask, trial CPAP 10cmH2O with FiO2 0.6
      2. If further escalation, consider increasing CPAP 12-15 cmH2O + 60-100% O2 if needed.
      3. If not, IMV.
  1. Category Red
    1. Clinical Status – RR >= 20bpm with SpO2 =< 94% on 15L/min O2 via non rebreathe mask and/or patient unable to tolerate CPAP mask, rising FiO2 needs significant clinical decline
    2. Action – Urgent Critical Care review and preparation for intubation.

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