COVID-19: How to safely optimize NIV therapy

Understanding which ventilation technique is appropriate for each patient can help improve patient care and assist clinical teams for success. There are different ways to support COVID-19 patients with NIV therapy and depending on the route of the best course of treatment, each comes with different considerations. Below are the most common NIV therapies, with recommendations on how the transmission risk can be reduced:

• High-Flow Nasal Cannula (HFNC): If oxygen delivered via HFNC is an option for patients with mild hypoxemic respiratory failure:
  o Provide masks to be worn over the nasal cannula to reduce the potential for airborne virus transmission. 
  o Ensure timely endotracheal intubation and positive pressure mechanical ventilation if the patient’s clinical status deteriorates [3-4].
• Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP): If CPAP or BiPAP is considered appropriate in patients with mild hypoxemia and hypercarbia – such as patients with exacerbation of chronic obstructive pulmonary disease (COPD):
  o Use a well-fitted oro-nasal mask (or helmet, if available). Avoid use of nasal masks and/or nasal pillows, if possible.
  o Employ a dual-limb ventilator with filters placed at the ventilator outlets.
  o Using an appropriate and compatible expiratory port filter for single-limb non-invasive ventilators will reduce the risk of virus spread in the open patient room [5].

Of course, vigilance is required to ensure timely endotracheal intubation and positive pressure ventilation if a patient’s clinical status deteriorates. If a patient develops acute respiratory failure with documented or suspected COVID-19 infection fails trials of noninvasive respiratory, they may require endotracheal intubation and positive pressure mechanical ventilation [3-4, 6]. Some ventilator models can be used for both non-invasive ventilation and invasive ventilation, shifting modes as the clinical need changes with the patient.

Our mission to improve lives is more relevant now than ever. We are working vigilantly to support healthcare providers around the world and provide them with clinical guidance relating to the use of our professional healthcare products and solutions and any other information that may be helpful during this crisis, like the information in this article. Our gratitude goes out to everyone who is fighting against COVID-19 and who are trying to do what they can to help patients. Stay safe and healthy. 

[1] World Health Organization (WHO).  Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: Interim guidance.  https://apps.who.int/iris/rest/bitstreams/1266296/retrieve

[2] Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).  Centers for Disease Control. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

[3] Josh Farkas.  COVID-19. Internet Book of Critical Care (IBCC), https://emcrit.org/ibcc/covid19/#noninvasive_respiratory_support, March 2, 2020.

[4] David S. Hui, Benny K. Chow, Thomas Lo, et al. Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks. Eur Respir J. https://erj.ersjournals.com/content/53/4/1802339.long, 2019; 53: 1802339 [https://doi.org/10.1183/13993003.02339-2018].

[5] (https://www.usa.philips.com/healthcare/product/HCNOCTN113/respironics-niv-filter-circuit/overview)

[6] Basem M. Alraddadi, Ismael Qushmaq, et al.  Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Influenza Other Respir Viruses. https://onlinelibrary.wiley.com/doi/epdf/10.1111/irv.12635, 2019; 13:382–390.