This document provides a framework to guide clinicians in the delivery of respiratory supports to adult patients who have COVID-19 and are admitted to inpatient wards outside of intensive care. It is designed to inform local policies and procedures, which should be current and reviewed regularly.
When an adult patient has COVID-19 and cannot maintain adequate oxygen saturations (SpO2), it is well recognised that the timely and effective use of respiratory supports plays a key role in reducing the length and severity of the course of COVID-19. It can also reduce the likelihood of admission to intensive care by up to 25%. Therefore, it is essential to develop the capability and capacity to provide these supports outside of intensive care to improve patient outcomes. In addition, this can prevent intensive care admissions which will support intensive care capacity during the current outbreak of the COVID-19 Delta variant of concern in NSW.
This guide is intended for use by clinicians in local health districts (LHDs) across NSW who are:
This information is not a substitute for healthcare providers’ professional judgement. Specific information about the individual patient and consultation with other medical authorities must be considered as appropriate.
There is now substantial evidence of the efficacy of stepwise escalation of respiratory supports for adult patients with COVID-19 who require ward-based care outside of intensive care. Timely delivery of the most appropriate respiratory support for a patient’s condition can improve patient outcomes and support patient flow by reducing admissions to intensive care. The National COVID-19 Clinical Evidence Taskforce has made evidence-based recommendations for the use of respiratory supports for adults with COVID-19. This clinical practice guide is based on these recommendations as the best synthesis of current available peer-reviewed evidence.
To improve the applicability of this clinical practice guide within LHDs across NSW, verbal discussions with senior NSW Health respiratory physicians and nurses were conducted, summarised and themed. This has:
This guidance is based on current evidence and supported by the expert clinical consensus of a multidisciplinary team of senior clinicians from the ACI Respiratory Network. It was developed in consultation with senior clinicians from the Agency for Clinical Innovation’s (ACI) Intensive Care NSW (ICNSW) COVID-19 Clinical Community of Practice.
The Delta variant is a COVID-19 variant of concern (VOC) that poses issues for respiratory management as it is likely to be associated with more severe acute disease, particularly in a younger cohort of patients. It is predominantly transmitted through infected droplets and aerosols via the respiratory route, with the dominant mode of virus transmission through infected aerosols and droplets released while breathing and coughing.
The addition of respiratory supports adds limited additional risk to the transmissibility of the Delta VOC in inpatient environments, if they are provided in alignment with the
COVID-19 Infection Prevention and Control Manual. Further information on the respiratory supports outlined in this document in relation to aerosol generation can be found in
Prone positioning has been shown to improve ventilation and oxygenation in adult patients with COVID-19. Awake prone positioning of patients with hypoxaemic respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation. It is a cost-effective, safe and comfortable intervention for most patients.
Prone positioning should be initiated by the first clinician caring for an adult patient with COVID-19 who recognises oxygen desaturation.
The recommendations for prone positioning of adult patients with COVID-19 who require ward-based care outside of intensive care in NSW are:
When caring for patients with COVID-19, clinicians need to determine an SpO2 target range for if/when respiratory supports are required. The
recommended target ranges are:
Once the target range is set for patients,
altered calling criteria should be considered as the suggested target ranges above are clinically appropriate for adults with COVID-19, but sit outside current NSW
between the flags standard calling criteria. Respiratory supports can then be delivered to maintain SpO2 within this target range.
All adult patients with COVID-19 requiring O2 are at risk of further deterioration. At the time of admission and as required through their clinical journey, expectations and limits of therapy should be discussed and established. In addition, several evidence-based systemic therapeutics should be considered as per
Care of adults with COVID-19 in acute inpatient wards model of care for NSW Health clinicians.
Standard O2 delivery devices deliver a fixed O2 flow to patients requiring supplemental O2. They do not provide any ventilatory assistance or additional positive end expiratory pressure (PEEP).
The recommendations for the use of standard O2
delivery devices for adult patients with COVID-19 who require ward-based care outside of intensive care in NSW are:
The recommendations for the use of HFNPO2 for adult patients with COVID-19 who require ward-based care outside of intensive care in NSW are:
CPAP is the non-invasive application of PEEP (with or without entrained oxygen) using a mask rather than in conjunction with invasive techniques such as intubation.
The recommendations for the use of CPAP for adult patients with COVID-19 who require ward-based care outside of intensive care in NSW are:
Some special considerations around the use of CPAP are:
Non-invasive ventilation (NIV) refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device, so that invasive techniques such as intubation are not required. NIV can deliver a range of modes that provide additional respiratory support beyond CPAP. These modes can decrease carbon dioxide (CO2 ) levels and reduce the
work of breathing.
Provision of NIV should:
The recommendations for the use of NIV for adult patients with COVID-19 who require ward-based care outside of intensive care in NSW are:
There are special considerations for nursing staff caring for patients with COVID-19 who are receiving respiratory supports. The recommendations for this are:
Weaning patients from respiratory support at the clinically appropriate time is essential to aid successful recovery from COVID-19. The recommendations for this are:
When patients with COVID-19 deteriorate and reach the maximum level of respiratory support that can be provided safely in the ward environment, escalation to intensive care may be appropriate.
The recommendations for escalation to intensive care for adults with COVID-19 are:
When patients with COVID-19 deteriorate and their documented limits of therapy have been reached, end of life care is most appropriate and should be prioritised.
The recommendations for limits of therapy and end of life care in adults with COVID-19 are:
The current COVID-19 Delta variant of concern (VOC) outbreak has seen high numbers of adult patients admitted to acute inpatient environments. In the context of:
The addition of respiratory supports adds limited additional risk to the transmissibility of the COVID-19 Delta VOC.
Normal breathing generates particles that are potentially infectious. In adult patients with COVID-19 ensure staff wear appropriate PPE and patients are managed in areas as per IPAC manual.
Coughing produces many more particles than quiet breathing. Therefore, the risk of transmission is high in adult patients with COVID-19. Clinical staff should stay out of the 'blast zone' of cough when possible.
Talking, exercise, shouting and spirometry also increase the generation of particles.
This includes the following high flow humified oxygen, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). These respiratory supports generate
limited additional risk of transmission of virus particles. In adult patients with COVID-19, these therapies should be delivered when required and not withheld based on aerosol generation. They can be delivered in cohorted COVID-19 patient areas of designated COVID-19 wards. Outside of these environments, respiratory support should be delivered as per
Respiratory network COVID-19 clinical intelligence group (Helen Kulas, Professor Peter Wark, Assoc/Professor Lucy Morgan, Associate Professor Jonathan Williamson, Nick Yates, Dr David Joffe, Dr Daniel Murphy)
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning