What are current recommended strategies to minimize the need for intubation?

Posted on May 16, 2020 by Madalon Burnett

Summary

It is important not to delay intubation in a patient that requires it. If a patient is not responding to standard therapy, high flow oxygen and awake proning are the current recommended strategies that may reduce the need for intubation. 

I.   Introduction

  • The following information relates to strategies that can prevent the need for intubation. It is important not to avoid intubation in patients that require intubation as delayed intubation can harm both the patient and healthcare workers (1,2)

II.   High flow oxygen

  • Placing hypoxic patients on high flow oxygen via nasal cannula reduces the number of days on mechanical ventilation during  acute hypoxemic respiratory failure. This study was published in 2015 and therefore relates to causes of hypoxia that are not COVID-19 (3)
  • The BCCDC and BC Ministry of Health recommend using high flow nasal cannula to treat hypoxia associated with COVID as this may prevent intubation and mechanical ventilation (4)

III.   Awake proning

  • Prone position results in better oxygenation and pulmonary heterogeneity in patients with COVID-19, and was a strategy used in the Jiangsu province of China, an area with lower mortality rates than other areas of China during the COVID-19 outbreak (5)
  • The BC CDC recommends trying awake proning as a strategy to promote oxygenation in hypoxic patients prior to intubation (6)

IV.   Fluid Management

  • In the Jiangsu province of China, experts suggest that restrictive fluid resuscitation was an intervention that helped lower their mortality rates. Fluid overload can cause pulmonary edema and prevent oxygenation (5)
  • Alberta Health Services recommends “Use conservative fluid management in patients with COVID-19 when there is no evidence of shock or overt hypovolemia. Patients with COVID-19 should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation and fluid accumulation may worsen oxygenation. Hypotonic fluids, starches and albumin should generally be avoided. Minimization of fluid accumulation and extra-vascular lung water via reduction of non-essential fluid intake and correction of positive fluid balance with diuretic therapy or mechanical fluid removal with CRRT” (7)

V.   Drug Therapy

  • According to the BC CDC, “Within British Columbia, the use of specific COVID-19 drug therapies outside of clinical trials is NOT recommended.” This recommendation is based on guidelines from international organizations such as the WHO (8).

VI.   Non-invasive Positive Pressure Ventilation (NIPPV)

  • NIPPV is used as a treatment for acute respiratory failure in heart failure and COPD patients (9)
  • NIPPV is an aerosol generating procedure, and therefore has added risks for healthcare workers in the context of the COVID-19 pandemic (9)
  • NIPPV is a controversial treatment for respiratory failure due to COVID-19

Against NIPPV

  • The Alberta Health Services Scientific Advisory  group recommends against NIPPV for patients experiencing acute respiratory failure, unless the respiratory failure is known to be from CHF or COPD. This recommendation is because the risks of aerosolization during the pandemic are greater than any proven benefits (9). 
  • High flow oxygen is more likely to prevent intubation than NIPPV (3)

For NIPPV

  • The JAMA Clinical Guidelines Synopsis recommends a trial of NIPPV if high flow oxygen is not available, though they admit the evidence to support this treatment is of low quality (10)
  • Consider helmet delivery of NIPPV over face mask, as NIPPV delivered by helmet reduces the intubation rate in patients with acute respiratory distress syndrome over NIPPV delivered via face mask (11)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. UpToDate [Internet]. Uptodate.com. 2020 [cited 2020 May 14]. Available from: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-and-airway-management-issues?search=covid%2019%20when%20to%20intubate&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H369339320
  2. COVID-19 Message to Respiratory Therapists [Internet]. The Toronto Centre of Excellence in Mechanical Ventilation. 2020 [cited 2020 May 14]. Available from: https://coemv.ca/covid-19-message-to-respiratory-therapists/
  3. Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. The New England journal of medicine [Internet]. 2015 [cited 2020 May 14];372(23):2185–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25981908
  4. ‌High-Flow Oxygen During the COVID-19 Pandemic [Internet]. 2020 [cited 2020 May 14]. Available from: http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_HighFlowOxygenRecommendations.pdf
  5. Sun Q, Qiu H, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Annals of Intensive Care [Internet]. 2020 Mar 18 [cited 2020 May 14];10(1). Available from: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-020-00650-2
  6. ‌Coronavirus COVID-19 BC Centre for Disease Control | BC Ministry of Health [Internet]. [cited 2020 May 14]. Available from: http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_OxygenTherapyIntubationGuidelines.pdf
  7. ‌Care of the Adult Critically Ill COVID-19 Patient Annex D Provincial Critical Care Communicable Disease Working Group Critical Care Strategic Clinical Network Alberta Health Services [Internet]. Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-care-adult-critically-ill.pdf
  8. Clinical Reference Group Recommendation: Therapies for COVID-19 [Internet]. [cited 2020 May 14]. Available from: http://www.bccdc.ca/Health-Professionals-Site/Documents/Recommendation_Unproven_Therapies_COVID-19.pdf
  9. COVID-19 Scientific Advisory Group Rapid Response Report Updates on Recommended Use of Non-invasive Ventilation in AHS Acute Care Facilities During the COVID-19 Pandemic Key Research Questions [Internet]. 2020. Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-sag-niv-rapid-review.pdf
  10. ‌Poston JT, Patel BK, Davis AM. Management of Critically Ill Adults With COVID-19. JAMA [Internet]. 2020 Mar 26 [cited 2020 May 16]; Available from: https://jamanetwork.com/journals/jama/fullarticle/2763879
  11. Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome. JAMA [Internet]. 2016 Jun 14 [cited 2020 May 16];315(22):2435. Available from: https://jamanetwork.com/journals/jama/fullarticle/2522693

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.