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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 Continuous evaluation and titration of ongoing interventions ensures optimal results. The respiratory manifestations of [[COVID-19]] may require some oxygen supplementation to [[ventilation|ventilatory support]].
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| 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]] will 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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| *Surviving Sepsis Campaign has the following recommendations regarding the use of [[oxygen therapy|supplemental oxygen]] in adults [[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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| **It is strongly recommended (with moderate-quality evidence) to start the [[oxygen therapy|supplemental oxygen]] if the [[oxygen saturation|Spo2]] is < 90%. A weak recommendation states starting the supplemental oxygen at < 92% saturation.
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| **In [[COVID-19]] positive adult [[patients]] with acute [[respiratory failure|hypoxemic respiratory failure]] on [[oxygen therapy|supplemental oxygen therapy]], [[oxygen saturation|Spo2]] should be maintained no higher than 96% (strong recommendation by Surviving Sepsis Campaign). This 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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| *According to Chinese experts based on there experience with [[COVID-19]] patients, both HFNC and NIPPV methods should probably be utilized in patients with 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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| *NIV methods are easier and comfortable to use and work by inducing [[PEEP]] thus decreased the respiratory workload.
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| *Sufficient evidence to prove the superiority of one of the methods (HFNC or NIPPV) is unavailable as of now (July 2020). Limited studies have suggested that HFNC improves survival and lowers the intubation rate.<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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| ====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>
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| *Surviving Sepsis Campaign (SSC) has the following recommendations regarding the use of HFNC 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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| **In [[COVID-19]] positive adult [[patients]] with acute [[respiratory failure|hypoxemic respiratory failure]] despite [[oxygen therapy|supplemental oxygen therapy]], a weak recommendation suggests using HFNC over conventional [[oxygen therapy]]. A systematic review and meta-analysis of 9 [[Randomized controlled trial|RCTs]] showed that High Flow Nasal Cannula (HFNC) reduces the need for [[intubation]].
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| **A weak recommendation (low-quality evidence) also prefers using HFNC 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 NIPPV is also one of the considering factors.<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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| ====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|non-invasive positive pressure ventilation (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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| * Surviving Sepsis Campaign (SSC) has the following recommendations regarding the use of [[Positive airway pressure|Non-invasive positive pressure ventilation (NIPPV)]] in adult [[COVID-19]] patient with [[respiratory failure|hypoxemic respiratory failure]]:<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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| **A weak recommendation (very low-quality evidence) suggests a trial of [[Positive airway pressure|NIPPV]], if HFNC is not available and [[endotracheal intubation]] not urgently indicated. with close monitoring and short-interval assessment for worsening of respiratory failure.
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| **The SSC demonstrated its uncertainty regarding the safety and efficacy of helmet NIPPV in [[COVID-19|SARS Cov2]] patients. Another study advocates and recommends the use of helmet 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>
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| * Mechanical ventilation can be used in patients who have labored breathing and are unable to maintain adequate gaseous exchange leading to [[hypoxemia]] and/or [[hypercapnia]].
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| * Common clinical indications of mechanical ventilation include moderate to severe [[dyspnea]], [[respiratory rate]] (RR) > 24-30/min, accessory muscle use for breathing, and abdominal paradox. It may also be used in patients who have an inadequate arterial partial pressure of oxygen or critically low PaO2 (PaO2 < 70 mm Hg), hypercapnia PaCO2 > 45 mm Hg, and PaO2/FiO2 ≤ 300 (corrected for altitude).
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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>
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| *'''Mode''': No mode of ventilation has been suggested to be superior to others.
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| *'''[[Positive end-expiratory pressure|positive end-expiratory pressure (PEEP)]]''': The commonly used [[PEEP]] in the [[COVID-19]] patients in Wuhan, China was less than 10 cm H2O. It is advised that after lung recruitment maneuvers, is to set PEEP at 20 cm H2O and titrate down in a decrement of 2 to 3 cm H2O each time until the goals of oxygenation, plateau pressure, and compliance are all achieved. 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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| **''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]].
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| *'''[[Lung volumes#Measurement and values|Tidal volume]] (Vt)''': Upto a maximum of 6 ml/kg of ideal body weight and lower inspiratory pressures.
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| * '''Plateau pressure''' (Pplat): < 28 to 30 cm H2O
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| *PEEP must be as high as possible to maintain the driving pressure (Pplat-PEEP) as low as possible (< 14 cmH2O)
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| Marini et al. suggest
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| **Lower PEEP: “type L,” characterized by low lung elastance (high compliance), lower lung weight as estimated by CT scan, and a low response to PEEP
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| **Higher PEEP: Initially it was recommended that the guidelines for [[ARDS]] must be followed for respiratory support in [[COVID-19|SARS Cov2]] patients. But the data from China helped inform and reform regarding the strategies. '''In Wuhan, patients with acute hypoxemic respiratory failure due to COVID-19 have a poor tolerance to high PEEP, likely as the result of the direct and severe lung damage by the [[SARS-CoV-2]] virus and inflammatory reactions.'''<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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| ==Stratagies to improve oxygenation==
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|
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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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| *Research has shown that [[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>
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| * [[Mechanical ventilation initial ventilator settings#Proning|Prone position]] for awake patients during spontaneous or assisted breathing during 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 Surviving Sepsis Campaign 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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|
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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 [[sedative]]s and [[analgesic]]s. In [[COVID-19-associated acute respiratory distress syndrome|CARDS]] patients, Richmond Agitation Sedation Scale (RASS) score of (+2 to +4) indicates the use of deep [[sedation]] with [[paralytics]]. The use of short-term (24– ƒ48 hours) and intermittent muscle relaxation is recommended. Prone position ventilation may also require muscle relaxation along with sedation. Use of [[paralytics]] is not recommended in an unless 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'''
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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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| |-
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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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| * Adequate dosage and time for paralytic drugs
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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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| |[[Intubation]], NIV, manual [[ventilation]], [[CPR]], [[tracheostomy]] and [[bronchoscopy]]
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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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| *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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| |-
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| |Non-Invasive ventilation (HFNC and [[Positive airway pressure|NIPPV]])
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| *Both HFNC and [[Positive airway pressure|NIPPV]] methods used in [[COVID-19]] patients generate [[aerosols]]. Concerns have been raised for a possible risk for transmission of [[COVID-19]] to health care personnel.<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>
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| *With the judicious use of the standard precautions and protective measures, the results for the aforementioned interventions have been promising. So, 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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| |}
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| <br />
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