COVID-19 QUESTIONS

1. Differences between H-type and L-type COVID-19.

2. Which type is more dangerous between H-type and L-type COVID-19?
3. What is the treatment for H-type and L-type COVID-19?
4. Which ventilator setting is good option for COVID-19 patient? SIMV or P-SIMV mode?
5. Which one use more aerosol generating procedures (AGP), nasal prong or high flow nasal
cannula?
6. What is the reason prone positioning for the COVID-19 patients?
The Berlin Definition of ARDS

The Berlin definition of ARDS requires the following four criteria:

1. Acute onset (within 1 week)

2. Bilateral opacities on chest xray or CT
3. PaO2/FiO2 ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
4. Must not be fully explained by cardiac failure or fluid overload

The severity of ARDS is graded using this scale:

Severity PaO2/FiO2 (on PEEP/CPAP >5) Mortality (all cause, cohort)

Mild 200-300 27%
Moderate 100-200 32%
Severe <100 45%

Kigali Modification of Berlin Criteria for ARDS

The Berlin definition of ARDS has limited applicability in settings where blood gas analyzers, chest
radiographs, and/or positive pressure ventilation are not reliably available. The Kigali Modification to
the Berlin criteria has been developed to address this gap (Riviello et al).

The Kigal modification requires the following four criteria to diagnose ARDS:

1. Acute onset (within 1 week or less)

2. Bilateral opacities on chest xray or ultrasound not fully explained by pleural effusions or
masses
3. SpO2/FiO2 <315 (no PEEP requirement; SpO2 must be <=97% for accurate estimation by
this method).
4. Must not be fully explained by cardiac failure or fluid overload

Key differences in the Kigali Modification include allowing ultrasound as a method of identifying
pulmonary opacities, the use of SpO2 instead of PaO2, and the lack of requirement for PEEP. Several
studies have validated the use of SpO2 in place of arterial blood gases (Chen et al; Sanz et al; Brown
et al) and ultrasound in place of chest xray for diagnosing ARDS (Lichtenstein). One single center
study has validated the modification in ventilated patients (Vercesi et al). However, a large validation
study comparing the Kigali Modification to the Berlin Criteria is needed.

When patients are not mechanically ventilated, the FiO2 will need to be estimated.

See relevant sections in Inpatient Management (listed below) for options in patients that do not
require intubation and mechanical ventilation. Some of these can be performed in the ICU or outside
of the ICU depending on the institution:

 Oxygen Escalation Pathway

 Oxygen Weaning
 High Flow Nasal Cannula
 Non-Invasive Ventilation
 Awake Prone Positioning (see below for ventilated proning)\

Candidacy

There are several potential indications for intubating a patient with respiratory failure. These
include:

 Persistent or rapidly worsening hypoxemia despite maximal oxygen therapies

 Ventilatory failure (e.g. hypercapnia, fatigue, apnea or obstructive disease)
 Severe work of breathing
 Altered mental status that impairs either ability to protect airway or comply with oxygen
therapies
 Mechanical airway obstruction
 Presence of a shock state
 Presence of severe acidosis

Ultimately, the decision to intubate is based on multiple factors including the patient’s complete
clinical scenario (including goals of care) as well as the availability of local resources to safely manage
the airway and provide mechanical ventilation. Of note, early in the pandemic there were anecdotal
reports advocating for earlier intubation of COVID patients as compared to other patients with
respiratory failure from other causes. However, there are no data to support this practice. Intubation
criteria for COVID patients with respiratory failure are generally the same as for non-COVID patients
with respiratory failure.

Initial Ventilator Settings

1. Obtain STAT portable chest xray: to confirm endotracheal tube location.

1. Prioritize CXR and vent settings over procedures (such as central venous catheter
placement) if possible.
2. If portable chest x-ray is not available, confirm endotracheal tube placement with
bilateral breath sounds and CO2 detection

2. Ensure adequate sedation

3. Set mode to volume control (AC/VC)

1. In some settings airway pressure release ventilation (APRV)is used

4. Set Initial tidal volume (Vt):

1. Vt = 6 ml/kgIBW (based on ideal body weight [IBW]), see ARDSNet Table to look up

tidal volume by gender and height in cm or inches.)
5. Set initial respiratory rate:

1. Typical starting rates will be 16-24 titrated to goal minute ventilation of 6-8 L/min
2. Consider starting rates of 24-28 titrated to goal minute ventilation of 8-12 L/min in
setting of acidosis (pH < 7.25) pre-intubation. If blood gas is unavailable, higher initial
minute ventilation should be targeted for patients with a pre-intubation respiratory
rate above 35.

6. Set Initial PEEP based on BMI (empirically chosen targets):

1. BMI < 40: PEEP 5

2. BMI ≥ 40: PEEP 10
3. These should be readjusted after half an hour based on FiO2 and ARDSnet grid
(see ARDS Oxygenation)

7. Set Initial FiO2: 100% on intubation then rapidly wean to SpO2 92-96% (Barrot et al)

(see ARDS Oxygenation)
8. Obtain an arterial blood gas (preferred) or a venous blood gas within 30 minutes

1. Calculate P/F ratio from initial post-intubation ABG. Adjust oxygenation as described
in ARDS Oxygenation.
2. Goal pH 7.20 to 7.45. Adjust ventilation as described in ARDS Ventilation.

Mechanical Ventilation

This section addresses the management of mechanical ventilation for COVID ARDS specifically, not
mechanical ventilation for other indications. It discusses the use of AC/VC as a ventilatory mode.
Some settings may prefer APRV, which is not discussed in detail. Pressure support ventilation (PSV)
mode is often used as the patient is recovering and preparing for extubation.

This section does not discuss managing COVID ARDS with concurrent obstructive lung disease
(asthma, COPD), which ideally should be done by experienced clinicians only.

Improper ventilator management can permanently damage a patient’s lungs. Ventilator

management requires significant infrastructure as well as training and expert guidance to call on if
needed. This section assumes providers have some background knowledge about mechanical
ventilation. See below for links to introductory material on mechanical ventilation.
Lung Protective Ventilation

Patients with ARDS receiving mechanical ventilation are at risk of lung damage, often referred to as
ventilator induced lung injury (VILI). However, steps can be taken to reduce the risk of VILI and
decrease mortality for patients with ARDS. This is referred to as lung protective ventilation (LPV).

LPV involves adjusting ventilator settings to achieve the following goals:

 Tidal volumes (Vt) of 4-6ml/kg ideal body weight (IBW)

 Plateau pressures (pPlat) less than 30cmH2O
 Driving pressures less than 15cm H2O
 Driving pressure is equal to pPlat - PEEP

ARDS Ventilation: Respiratory Rate and Tidal Volume

Minute Ventilation (respiratory rate x tidal volume) helps control pH and PCO2.

 Titrate minute ventilation to pH and not PCO2 in most circumstances!

 Low tidal volumes are needed to protect the lungs from ventilator induced lung injury and
promote lung healing. To achieve this, we tolerate hypercapnia (functionally no limitation
unless clinical limits like seizure or managing increased ICP) and acidemia (pH > 7.2) (Ijland et
al).

Adjusting ventilation parameters

 First, set tidal volume

 Follow ARDSnet ventilation where possible: Starting tidal volume of 6 cc/kgIBW.

 Tidal volumes should always be within the 4-8 cc/kg range, ideally 4-6cc/kg based
on Ideal Body Weight [IBW]. See ARDSNet table to look up tidal volume by gender and
height in cm or inches.

 Next, adjust rate to meet goal pH 7.20-7.45:

 The respiratory rate often has to be high to accommodate low tidal volumes; typical RR is
20-35 breaths/minute. In patients with obstructive lung disease these are lower.

 If pH > 7.45, decrease respiratory rate

 If pH 7.10-7.25, then increase respiratory rate until pH > 7.25, or PaCO2 < 30
(maximum RR= 35 breaths/minute and check for autoPEEP (also known as intrinsic
PEEP)

 If pH < 7.10 despite maximum RR:

 Address reversible causes of metabolic acidosis

 Increase tidal volume up to 8cc/kg IBW or plateau pressure 30cmH20
 Deepen sedation to RASS -3 to -5 or paralyze if needed
 Initiation of prone ventilation (may improve V/Q matching and ventilate better)
 Consider extracorporeal membrane oxygenation (ECMO) if available and none of the
above is effective

ARDS Oxygenation: PEEP and FiO2

PEEP and Fi02 drive oxygenation. The goal is to deliver a partial pressure of oxygen to perfuse tissues
(PaO2 ≥ 65, Sp02 ≥ 92%) while limiting lung injury from high distending pressures (with plateau
pressures ≤ 30) and oxygen toxicity (with FiO2 ≤ 60%, SpO2 ≤ 96%). 

Lower limit goals for PaO2 / SpO2 are widely debated; PaO2 > 55 and SpO2 >88% are also commonly
used. Many clinicians use PaO2/FiO2 (called the P/F ratio) to guide oxygenation as it is a shorthand
way of assessing the A/a gradient for the patient and seeing if their oxygenation is
improving. SpO2/FiO2 ratio can be used if arterial blood gases are unavailable

 If FiO2 >60%; patient requires ventilator optimization (ask a specialist). If persistent, see
the Refractory Hypoxemia pathway.

 It is reasonable to put a desaturating patient temporarily on 100% FiO2, but remember to

wean oxygen as rapidly as possible

 If pPlat >30 see the Mechanics: Plateau Pressure.

Adjusting Oxygenation Parameters:

1. Typically, set PEEP and FiO2 according to the ARDSnet Tables:

1. Within half an hour of initial ventilation settings (typically PEEP 5 for BMI <40 and
PEEP 10 for BMI >40) reset PEEP and FiO2 to target oxygenation SpO2 92-96% using
the following tables:

BMI < 40: ARDSnet LOW PEEP table:

FiO2 0.3 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0. 0.9 1
9
PEEP 5 5 8 8 10 10 12 14 14 14 16 28 18-24

BMI ≥ 40: ARDSnet HIGH PEEP table

FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.5-0.8 0.8 0.9 1 1
PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24

Higher levels of PEEP can cause hypotension. It is important to monitor blood pressure when
increasing PEEP.
2. Readjust Frequently

1. PEEP and Fi02 should be adjusted if:

1. SpO2 <92% or >96% (do not use more oxygen or PEEP than is needed)
2. PaO2 <65 or >100
3. pPlat >30 (see this pathway)

3. PEEP Optimization (If Needed and Familiar):

1. In the setting of persistent hypoxemia, elevated plateau pressures, or for provider

preference, PEEP optimization strategies could be considered. There is little data for
how to determine optimal PEEP, and it is recommended that these be conducted by
people familiar with the methods.

1. Best PEEP trial

2. Pressure Volume Tools
3. Esophageal balloons. Special cases (e.g. morbid obesity, burns) may need extra
diagnostics, such as esophageal balloons, which we do not recommend for routine
use given limited resources and infection risk.
4. Stress index (Video)

Plateau Pressure:

It is important to avoid elevated plateau pressures (with goal ≤ 30) which can indicate relative lung
overdistention (Slutsky et al).

1. Check plateau pressure with every change in tidal volume, PEEP, or clinical deterioration
(worsening oxygenation) but not as part of routine practice. In order to accurately
measure plateau pressure, the patient must be passive (i.e. not actively breathing) on
AC/VC mode with a constant flow delivery (as opposed to decelerating flow delivery).
2. If plateau pressure is >30 cm H20, then decrease tidal volume by 1 mL/kgIBW (minimum
4 mL/kgIBW)
3. If plateau pressure is < 25 cm H20 and tidal volume < 6 mL/kgIBW, then increase tidal
volume by 1 mL/kgIBW until plateau pressure is > 25 cm H2O or tidal volume = 6
mL/kgIBW
4. If plateau pressure is < 30 cm H20 and patient is breath stacking or dyssynchronous, then
increase tidal volume in mL/kgIBW increments to 7 mL/kgIBW or 8 mL/kgIBW while
plateau pressure is < 30 cm H20

Compliance:

Compliance measures can give an indication about whether a patient’s lung stiffness is improving or
declining over time, and can help with prognostication and management.

Troubleshooting
Resistance: Troubleshooting increased Peak Inspiratory Pressure due to high resistance: Work
outside (machine) to inside (alveoli); circuit problem, ETT kink/occlusion/biting, ETT
obstructed/malpositioned, large airway obstruction (mucous plug), small/ medium airway
obstruction (bronchospasm); auscultation & passing a suction catheter can quickly eliminate many of
these.

Compliance: Troubleshooting increased Peak Inspiratory Pressure due to reduced compliance: Work

outside (patient extra-pulmonary factors) to inside (alveoli): Patient dyssynchrony requiring
increased sedation (or temporary paralysis if refractory); intra-abdominal process; ET tube
malpositioned (into a single tube); pneumothorax; auto-PEEP (due to incomplete exhalation,
typically in setting of bronchospasm), parenchymal and alveolar process (flash pulmonary edema,
pulmonary hemorrhage).

Other Modes of Ventilation

PSV

This section is forthcoming

APRV

There exists significant practice variation around the use of bilevel ventilatory modes. APRV should
only be used by providers with experience and familiarity with this mode. At this time there are no
data to support the superiority of APRV in ARDS patients, including those with COVID-19. One recent
small study in Australia found that APRV was associated with decreased survival (Zorbas et. al).

Prone Ventilation

Early proning in COVID-associated ARDS requires intensive management but can significantly
improve oxygenation. Pronation is one of the only interventions shown to improve mortality in ARDS
(PROSEVA) (Guérin et al). In one representative study in 62 COVID patients on ventilators who
underwent prone positioning, as compared to 199 similar controls who met criteria for prone
positioning but did not receive the intervention, showed a multivariate-adjusted hazards ratio for
mortality of 0.57 (0.42-0.76) in the proned patients (Shelhamer et al).

For proning of non-intubated patients, please see Awake Proning.

Timing and Candidacy

Timing: We recommend early proning in severe ARDS (<36 hrs) and prefer to initiate proning prior to
use of continuous paralytics (or inhaled pulmonary vasodilators), despite the fact that in the
PROSEVA trial over 95% of patients in both the intervention and the control arm were on continuous
paralytics.

 We particularly recommend proning if a patient requires an FiO2 ≥ 60% to achieve an SpO2 ≥

92% (or PaO2 ≥ 65) with a P:F ≤ 150 (Guérin et al).
Eligibility: The only absolute contraindications are spinal cord injury, open chest, and unstable
airway. Patient size is not a contraindication. Other relative contraindications should be discussed by
the clinical team .

 For patients with a tracheostomy, we recommend that patients have their tracheostomy
replaced by oral endotracheal intubation (ETT) when possible, while recognizing that
decannulating a tracheostomy and placing an ETT poses an infectious risk to staff.
 Renal replacement therapy can be performed while prone, typically via a femoral line.
 Monitor for complications: Prone ventilation can lead to increased incidence of brachial
plexopathy in the context of increased pressure to anterior portions of the arm and shoulder
(Scholten; Goettler). Prone positioning for surgery has been associated with abdominal or
limb compartment syndromes, or Rhabdomyolysis (Kwee).

Intubated Proning Protocol

For proning of non-intubated patients, please see Awake Proning.

1. Prepare for Proning

1. Hold tube feeds for 1 hour prior to proning or supinating

2. Assemble all necessary tools (pillows, props, additional persons to assist)

2. Place Patient in Proned (“swimmer”) Position (some places have rotary beds)

1. Have one person hold ET tube and lines to assure they are not dislodged and
continuous medications are not disrupted

3. Measure effect of proning. 1 hour post-initiation of prone ventilation:

1. Obtain ABG. Compare pre-pronation PaO2/FiO2 to post-pronation PaO2/FiO2. Ideally

there should be a 0.1 change in FiO2 (maintaining the same SpO2) or >10% change in
PaO2 / FiO2. However, a lack of improvement may not be considered an absolute
indication to abandon proning.
2. Measure compliance and Plateau Pressure, PEEP, and FiO2
3. Assess tidal volume and Adjust Ventilation Parameters

1. If patient demonstrates improvement on proning:

1. Prone ≥16 hrs per 24 hrs. Supine ≥ 4 hrs per 24 hrs. Repeat every day. There is no day
limitation for maintaining prone ventilation and it should be repeated every day while
beneficial.
2. Discontinue neuromuscular blockade if initiated for dyssynchrony and re-assess.

2. If patient does not improve on proning:

1. Resupinate. Consider trying again the next day, as sometimes the recruitability of lung
tissue will change over time.

3. Consider discontinuing proning

1. If patient has improved and meets the goals listed below after supine for >4 hrs. If
patients do not meet criteria for supine ventilation then recommend ongoing prone
ventilation.

1. FiO2 < 60% to meet an SpO2 ≥ 92% (or PaO2 ≥ 65)

2. Plateau pressure < 30
3. pH > 7.25

4. Return to supine position emergently, if:

1. Unscheduled extubation
2. Endotracheal tube obstruction
3. Severe or significantly worsening hypoxemia, e.g. Sp02 <85% and consideration of
ECMO if available
4. Hemodynamic instability

Refractory Hypoxemia

If patient is hypoxic (PaO2 <75) despite PEEP optimization as above); and FiO2 > 0.6 or PaO2/FiO2
ratio < 150 then consider trying each of the following

1. Proning: Initiate early (if not already done)

2. PEEP: Adjust PEEP as above and request expert optimization if needed
3. Diuresis: Assess volume status. Diurese or remove volume by renal replacement therapy
if indicated.
4. Synchrony (Paralysis): Assess Ventilator Synchrony and Sedation to achieve ventilator
synchrony. If still dyssynchronous, consider Neuromuscular Blockade.

1. Assess for improvement in oxygenation (stable oxygenation metrics while being able
to reduce FiO2 by 0.1)
2. Try stopping neuromuscular blockade daily if possible, and discontinue completely if
the patient maintains PaO2>75 with FiO2<0.75 without it.

5. Inhaled pulmonary vasodilators: consider trial of continuous Inhaled Pulmonary

Vasodilators. Note however that there is no evidence of survival benefit of inhaled
vasodilators in ARDS.
6. ECMO Consultation: If available at your institution, if no improvement despite the above
steps, no contraindications, and any of :

1. Persistent PaO2 < 75 requiring FiO2 > 0.75

2. Plateau pressure >30
3. Refractory hypercapnia and pH < 7.2
Recruitment Maneuvers

A recruitment maneuver is the deliberate administration of a high airway pressure for protocolized
periods of time to open collapsed alveoli There are multiple protocols for performing recruitment
maneuvers. Studies have shown that recruitment maneuvers are associated with a temporary
increase in oxygen levels but do not impact clinical outcomes. (Brower et al; Meade et al; Oczenski et
al). A more recent study of recruitment maneuvers in combination with best PEEP trials found an
association with increased mortality (Calvacanti et al). Recruitment maneuvers can increase
intrathoracic pressure enough to affect blood return to the heart and thus hemodynamics. We do
not recommend regular use of recruitment maneuvers in the management of refractory hypoxemia.
Oxygen Care

Oxygen Escalation Pathway

Management of hypoxemia in COVID-19 requires selection of an initial appropriate oxygen delivery

system (e.g. nasal cannula), with escalation to a different system (e.g. simple face mask) capable of
higher oxygen flow if the patient worsens or is unable to reach their target oxygen saturation (SpO2).
Effective oxygen therapy is about finding a balance between delivering the lowest amount of
supplemental oxygen in order to achieve normal oxygen saturations for the patient. Hypoxemia is
harmful to patients, but so is giving too much oxygen (Girardis et al).

Goals of Oxygen Therapy

 Initiation

 Initiate oxygen if SpO2 is below ~94%

 If SpO2 is not available, initiate oxygen for patients with tachypnea (RR above 22) or
increased work of breathing

 Maintenance

 Target SpO2 92-96% on oxygen

 88-94% in patients with oxygen-dependent COPD

 If SpO2 is not available, one may consider empiric escalation of oxygen therapy for
tachypnea or increased work of breathing. However, these signs are weak surrogates for
SpO2 when titrating oxygen therapy.

Oxygen Escalation Pathway

1. Encourage self-proning if there are no contraindications.

1. Proning can be used with all types of oxygen delivery systems, or for patients on no
oxygen. For all oxygen systems, and non-invasive in particular, it is important to be
able to monitor the patient closely enough to ensure the risks of proning do not
outweigh the benefits.

2. If patient’s SpO2 is below 94% (or if patient is tachypneic, if no pulse oximetry is

available) initiate oxygen therapy

1. Deliver by nasal cannula at 1-6 L/min

3. If oxygen goals are not met by nasal cannula at <6 L/min then consider one of the
following:

1. Simple facemask at 6-10 L/min OR

2. Oxymizer pendant or mustache at 6-12 L/min OR
3. Venturi face mask at FiO2 0.4-0.6 (40%-60%)

1. Unlike simple and non-rebreather facemasks where you set the oxygen flow rate,
with Venturi masks you set the percent of oxygen (e.g. 40%). The percent of
oxygen is controlled using a valve attached to either the mask or the flowmeter.
First, select and attach the valve that corresponds to the correct FiO2 (or setting
the percent of oxygen if the valve is adjustable). The markings on the valve will
instruct you what flow rate to set. Because the valve blends pure oxygen with
room air, the actual flow delivered to the patient will be higher than the flow set
on the flowmeter.

4. If oxygen goals are still not met with the above options, consider escalation to the
following:

1. Non-rebreather facemask (at 10-15L/min, do not go below 10L or carbon dioxide can
be retained in the mask)

1. For patients with severe hypoxemia, some clinicians will place a non-rebreather
facemask on top of a nasal cannula. This is used when more intensive oxygen
delivery systems (e.g. high flow nasal cannula, non-invasive, and intubation) are
unavailable.

5. If oxygen goals are still not met, consider one of the options in the table below. The
clinical situation, availability of options at your institution, and goals of care discussions
should guide selection.

Option Ideal Candidate Contraindications (Many are Relative)

High Flow Nasal Patient with Patient Factors:
Cannula hypoxemia without
severe work of  Significant facial trauma or deformity
breathing or  Unavailability or inadequate oxygen supply to
increasing pCO2 complete treatment
 Need for emergent intubation (if within goals of
care)

Institutional Factors:

 Inability to administer IPC as required by your

institution

Non-Invasive Similar criteria as for Patient Factors:

Positive Pressure non-COVID patients,
Ventilation (BIPAP (e.g. flash pulmonary  Recent esophageal or gastric surgery
or CPAP) edema, heart failure,  Upper gastrointestinal bleeding
OSA, COPD flare) and  Facial or neurological surgery, trauma, or
those likely to only deformity
need it for a short
 Airway obstruction (eg, laryngeal mass or tracheal
period. Use of
prolonged NIPPV in tumor)
COVID19 patients  Inability to follow commands, protect airway, or
remains an area of clear secretions (eg, patients at high risk or
uncertainty with aspiration)
limited data to guide
 Need for emergent intubation (if within goals of
practice, potential
care)
risks to patients and
HCWs and
considerable practice Institutional factors:
variation.
 Inability to administer IPC as required by your
institution
 Limited staffing/inability to monitor

Intubation See Candidacy. Criteri Not available or not within goals of care

a in COVID are similar
to other patients (not
early intubation as had
been practiced earlier
in the epidemic)
Focus on Comfort Patients who do not Cultural norms and legal rules vary widely.
Measures want aggressive
measures or escalating
interventions will be
unlikely to accomplish
meaningful clinical
benefits. 

Oxygen Weaning Pathway

For patients on nasal cannula attempt weaning at least once a day:

1. Wean oxygen completely to off while monitoring at bedside with pulse oximetry, for at
least 5 minutes (unless the patient rapidly desaturates)

1. If oxygen saturation falls below SpO2 target (92% if no target specified), restart the
oxygen at the lowest flow rate necessary to meet the patient’s clinical (SpO2) goal.
2. If a patient maintains saturations above the clinical target without oxygen, oxygen
therapy may be discontinued.

2. Check oxygen saturation 30 minutes later and then again at 1 hour to ensure saturation
remains adequate without oxygen therapy.

For stable patients on simple, Venturi, or non-rebreather facemasks: attempt weaning at least once
a day by decreasing oxygen flow until goal oxygen saturation is met.

1. Minimum oxygen flow rates are required for non-rebreather face masks and Venturi face
masks to function properly, so do not decrease below the manufacturer recommended
flow.  Switch to a lower intensity oxygen delivery device once a patient is stable on the
minimum flow rate for their current oxygen delivery device.
1. Simple facemask: Minimum flow rate is often 4 to 5L/min. At this setting, the next
step in oxygen weaning is to switch to nasal cannula at 5 to 6L/min.
2. Venturi facemask: Minimum flow rate depends on the oxygen concentration setting
(FiO2). In general, once a patient is stable on 40%, they are ready to attempt
switching to nasal cannula at 5 to 6 L/min.
3. Oxymizer: There is no minimum flow rate, but once a patient is stable on 4 to 5 L/min
they can be switched to nasal cannula at 5 to 6 L/min.
4. Non-rebreather Facemask: Minimum is often 10L per minute. At this setting, the next
step is simple facemask at 10 L/min , or, if a simple facemask is not available, nasal
cannula at 5 to 6 L/min.

Oxygen Delivery Devices

Concerns about Aerosolization

The degree to which different oxygen delivery devices are thought to cause aerosolization remains
an area of active research, and the exact amount of aerosolization in each situation is not known.
Patient factors like coughing (which produces aerosols) and viral load, as well as the dynamics of
droplet particle size and dispersion, make this quite complex (Klompas et al). Meaningful distinction
between “safe” and “unsafe” levels of aerosols at this point is not possible. See Aerosols, Droplets,
and Fomites.

Flow rate: Lower oxygen flow rates hypothetically should reduce aerosols. However, a preprint
study in healthy volunteers showed that there was no variation in aerosol level between room air,
6L/min nasal cannula, 15 L/min non-rebreather, 30L/min high-flow nasal cannula and 60 L/min high-
flow nasal cannula regardless of coughing (Iwashyna et al).

This chart provides an overview, but is subject to change. Please follow your institution’s IPC
Practices regarding droplet or aerosol precautions. Aerosol Generating Procedures (AGPs) are
discussed here.

Device or activity High risk of More information

aerosolization?
Coughing Yes There is high aerosol generation with cough: 35 fold more
aerosols than are generated during extubation (Brown et al).
Cough-generated aerosols rapidly spread throughout a room
within 5 min (Lindsley et al). In one study, coughing was
associated with 10 times greater aerosols than speaking or
breathing (Hamilton et al).
Nebulizers Yes By design, nebulizer therapy produces aerosol particles. However,
the bacterial burden in these particles appears low (O’Neil et al). It
is not yet clear what the viral burden in these particles is. Jet
nebulizers produce sideways aerosol dispersion between 45-80
cm (Ferioli et al). Evidence for HCW infection risk is inconsistent
with 2 of 3 cohort studies found “some association” with therapy
(Tran et al). Anecdotal report of COVID-19 infection associated
with nebulizer therapy without use of PPE (Heinzerling et al).
Nasal Cannula No
Simple Masks No
and Non-
rebreathers
Venturi Masks Depends on Aerosol dispersion ranges from 30-40cm (Ferioli et al).
Humidification
High Flow Nasal Unknown Aerosols did not significantly increase with the use (up to 50LPM)
Cannula* in one small study of 10 healthy volunteers (Gaeckle et al). A
different study did find that HFNO emits aerosols, but these were
small (<1μm) particles generated by the machine and then passed
into the patient, not coalescing with respiratory particles, and
thereby unlikely to carry virus particles. (Hamilton et al)
BIPAP or CPAP* Unknown Aerosols did not significantly increase with the use (up to 20/10
cmH20) in one small study of 10 healthy volunteers (Gaeckle et
al). In one study, CPAP (with exhalation port filter) produced less
aerosols than breathing, speaking and coughing (even with large
>50L/m leaks) (Hamilton et al).
By type of mask:

 CPAP with orofacial vented mask: unable to determine

smoke dispersion because it occurred equally in all
directions.
 CPAP with nasal pillows: increasing air dispersion with
increasing positive pressure. At CPAP of 20 cmH2O a
maximum dispersion ~25-35 cm depending upon brand of
pillow interface.
 NIPPV with full face mask: Dispersion of 60-70 cm (single
limb circuit at inspiratory/expiratory pressures of 15/5
cmH2O) depending upon degree of lung injury. Dispersion
of ~90 cm observed at peak pressures of 23 cmH2O.
 NIPPV with helmet: Dispersion of 15-17 cm at
inspiratory/expiratory pressures of 22/10 cmH2O.
Dispersion distance of 18-27 cm observed at peak
inspiratory pressure of 30 cmH2O depending upon the
degree of lung injury.
 Double circuit and tight cushion connection at the head-
neck interface associated with negligible dispersion
(Ferioli et al).
Choosing a Delivery Device

It is important to know the oxygen supply capability at your facility as well as the consumption rates
for different delivery devices. Depending on a facility’s oxygen supply type (liquid oxygen versus
cylinders versus an oxygen generating pressure swing adsorption plant) some oxygen delivery
devices may not be practical. Even relatively well-resourced facilities with liquid oxygen can exhaust
supplies when ramping up use of devices like high-flow nasal cannula during a surge census. The
tools above can help you determine which delivery device to use and the flow rate needed.

Estimating Fraction of Inspired Oxygen (FiO2)

Oxygen Device O2 Flow FiO2

(L/min)
Nasal Cannula 1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
Simple Facemask 6-10 0.44-0.50
Non-Rebreather Mask (reservoir must be fully 10-20 Approx 0.6-0.8
inflated) At RR ~20 and Tidal Volume ~500
20 LPM flow = ~60% FiO2
30 LPM flow = ~70% FiO2
40 LPM flow = ~80% FiO2 (Farias
et al).

The values represent estimates of FiO2. Actual FiO2 delivered is dependent on multiple factors
including oxygen supply quality and patients minute ventilation. One general estimation rule is using
oxygen flow rate: FiO2 =0.21 + 0.03 x oxygen flow rate in L/min (Frat et al).

High-Flow Nasal Cannula (HFNC)

When available, high-flow nasal cannula is one option for selected patients for whom non-
rebreather or Venturi mask is not adequate to maintain goal oxygenation. While standard cannulas
and masks can provide flow rates of up to 15 liters per minute, an HFNC system delivers oxygen flow
rates as high as 80 L/min with variable concentrations of oxygen up to 100%.

In general, HFNC has been demonstrated as an effective intervention for management of acute
hypoxemic respiratory failure, improving survival (Frat et al) and reducing the need for mechanical
ventilation (Ferreyro et al).

 Several small studies show COVID-19 patients might avoid intubation using high-flow nasal
cannula (HFNC) (Demoule et al). This is especially true with concomitant proning. (Tu et
al; Despres et al; Xu et al).
 In one study of 293 COVID patients in South Africa, 47% percent were weaned off of HFNC
and did not require intubation (Calligaro et al).

For COVID, Indications for Use Might Include:

 A patient who is not meeting oxygenation goals on escalating therapies (e.g. facemask,
venturi mask, or non-rebreather) and does not meet criteria for intubation
 A patient who is not meeting oxygenation goals despite maximal oxygen therapy AND
intubation is either not available or not within goals of care,
 The patient does not need significant assistance with work of breathing or hypercapnia
(HFNC helps oxygenation but does not tend to help ventilation)

Contraindications:

 Patient cannot wear or tolerate device

 Increasing work of breathing or rising pCO2 should prompt a discussion about need for
intubation
 Inability to protect airway, or significant apnea
 Inadequate facility oxygen supply

Infection Control Implications:

 High flow nasal cannula is often labeled as an aerosol generating procedure (perhaps better
stated as an aerosol enhancing device); However, data to support this notion or quantify risk
to healthcare workers remain evolving; Nonetheless, all patients on HFNC should be
required to wear a surgical mask over the cannula (Leung et al; Ferioli et al).
 Heated and humidified oxygen must be used to avoid drying of mucous membranes and
secretions to prevent ciliary damage.
 Start with lower flow rates if possible to minimize potential aerosols
 Transport on HFNC is often not logistically possible, so conversion to non-rebreather is
recommended. In addition, non-rebreather may generate less aerosol.

Technical Use Recommendations:

 Standard HFNC systems usually consist of a high capacity flow meter, an air-oxygen blender
(typically connected to wall air and oxygen sources), tubing, cannula, and a heater-
humidifier.
 Some HFNC systems require a connection to high-pressure air in addition to high-pressure
oxygen sources. There are also several systems which do not require wall air and entrain
room air instead (either by Venturi effect or turbine)
 Humidification: For optimal patient comfort and adherence, HFNC systems should deliver
gas to the patient at 44 mg H2O/L or 100% relative humidity (Spoletini et al; Restrepo et al).
 HFNC consumes significant amounts of oxygen. For example, a patient receiving HFNC at 50
L/min and 0.8 FiO2 will consume approximately 37 L/min of oxygen and 13 L/min of air. A J-
type oxygen cylinder (1.45m height) contains 6800 liters of oxygen. At this rate, the cylinder
would last less than 3 hours.
Non-invasive Positive Pressure Ventilation (NIPPV)

When available, non-invasive positive pressure ventilation (e.g. CPAP, BiPAP) can be considered for
patients with the indications for which it would normally be used (e.g. OSA, COPD flare) whether or
not they have COVID.

In some institutions NIPPV is not a preferred method of delivering oxygen in worsening COVID-19-
related pneumonia/ARDS, though this is an area of active research and recommendations are often
changing. To see a summary of different guidance institutions recommendations, see our dashboard.

 Some early studies indicate it may help avoid intubation, though mortality statistics remain
unknown: In one study of 47 patients about a third of patients treated with CPAP were able
to avoid intubation (Alviset et al). In another study of 53 patients, 83% were successfully
treated with NIPPV (Brusasco et al). Careful patient selection is likely important in
determining candidacy and ultimately success.
 NIPPV may also be a way to help avoid ICU capacity overload and manage some patients on
the floor (Lawton et al).
 Patients on NIPPV need to be closely monitored as high tidal volumes or work of breathing
may risk patient-induced lung injury in ARDS (Brochard).
 Helmet NIV has been shown to be equivalent to high flow nasal cannula in moderate to
severe hypoxemia. Greico et al showed no significant difference in the number of days free
of respiratory support within 28 days, but did show decrease rate of endotracheal intubation
and number of days free of invasive ventilation in the helmet NIV group.

For COVID, Appropriate Indications Include:

 A patient has increased work of breathing or increasing pCO2 despite maximal oxygen
therapy (including HFNC if available) AND intubation is either not available, not within goals
of care, or not advised by the clinician caring for the patient.
 Similar indications as in non-COVID-19 patients:

 Obstructive Sleep Apnea or Tracheobronchomalacia: Patients on home nocturnal CPAP or

BiPAP should continue nocturnal NIPPV.
 Pulmonary edema
 COPD exacerbation and other reversible hypercapnia

Contraindications:

 NIPPV should be generally avoided in the same situations that NIPPV is avoided in COVID-19
negative patients (e.g., severe ARDS without short-term reversibility; the presence of
relative contraindications such as altered mental status, aspiration risk, secretions).

Infection Control Implications:

 Some institutions require that NIPPV be done with aerosol precautions, others do not. This is
an area of active research.

Technical Use Recommendations:

 Ensure masks/devices fit well and there is minimal air leak (which can cause significant
lateral air travel (Hui et al). Full mask is preferred over nasal-only masks.

Other Considerations:

 Prolonged use of NIPPV has been linked to malnutrition and should be monitored (Turner et
al).

Prone Positioning

Benefits, Risks, and Candidacy

Benefits of Proning

Proning is thought to provide physiologic benefits for patients with COVID-19: It improves
recruitment of alveoli in dependent areas of the lungs and may improve perfusion to ventilated
areas, improving ventilation-perfusion mismatching. Typically proning is used in ventilated ICU
patients, however the same benefits may be found in non-ventilated patients.

 Intubated Proning: Proning is one of the mainstays of ARDS therapy for intubated patients,
showing both 28 day and 90 day mortality benefit in the PROSEVA 2013 trial (Guerin). See
also Proning of Intubated Patients.
 Self-proning (non-intubated) in non-COVID patients: Small non-COVID-19 patient cohorts
(ARDS, post-lung transplant, and post-surgery) showed association with lab, radiographic, or
clinical improvement. 
 Self-Proning in COVID-19. Multiple trials have shown benefit in oxygen with proning (Coppo
et al; Weatherald et al). A randomized trial of 1121 patients showed that awake proning
improved outcomes: the hazard ratio for intubation was 0.75 (0.62−0.91), and the HR for
mortality was 0.87 (0.68−1.11) compared with standard care. (Ehrmann et al).

Risks of Proning

 Airway Obstruction (particularly if a patient is unconscious but not intubated)

 Dislodged Oxygen Delivery Device
 Facial Edema
 Pressure Ulcerations (especially the forehead and anterior chest)
 Pressure Neuropathies
 Patient Intolerance
 Intracranial Hypertension

Patient Selection

Self-proning can be used on stable patients (on room air or supplemental oxygen) and as a “rescue”
for those who have escalating supplemental O2 requirements.
 Self-proning can be done with any type of oxygen delivery system with careful consideration
and ideally multidisciplinary discussion for safety. At higher levels of oxygen, the patient may
require more frequent monitoring (see protocol below).
 The patient should ideally be able to move independently and have the cognitive and
physical status to supinate themselves if they become uncomfortable. This includes the
ability to safely manage their supplemental oxygen, IV tubing, SpO2 monitor and other leads
and attachments (within reason).
 In certain situations, patients who are unable to position themselves may be candidates
for assisted proning  as a “rescue” therapy. For example, assisted proning can be considered
if a patient has a low SpO2 (below 92%) on non-rebreather facemask, and HFNC, NIPPV, and
intubation are all unavailable or contraindicated (see below for additional considerations).

Contraindications:

 Absolute:

 Inability to Supinate or Pronate Safely (see above - exception is Assisted Proning)

 Imminent Risk of Intubation (see “when to stop self-proning”)
 Spinal Instability
 Facial or Pelvic Fractures
 Open Chest or Unstable Chest Wall
 Open Abdomen
 Unstable Airway (Patient with oral swelling, mass, tumor or other object obstructing the
airway)
 Unresponsive Patient (May be more likely to obstruct their airway)
 Intracranial Pressure Monitoring or Intracranial Hypertension
 Hemodynamic Instability (Blood pressure less than 80/40 or active up-titration of
vasopressors)

 Relative Contraindications:

 Altered Mental Status

 Nausea or Vomiting
 Non-invasive Positive Pressure Ventilation
 Copious Secretions
 Signs of Severe Respiratory Distress (Tripod position or obvious severe accessory
respiratory muscle use)
 Agitation
 Pregnancy
 Supporting Lines or Tubes at High Risk for Displacement (for example, a chest tube).

Awake Proning Protocol

For intubated patients, please see Proning of Intubated Patients.

Awake non-intubated proning requires careful attention to a number of steps:

1. Monitoring

1. Oxygen monitoring: Although many patients experience improvement in oxygenation

with pronation, it is possible that some patients may get worse. Therefore, it is
important to have a plan for patient monitoring during pronation. However, the type
and frequency of monitoring during pronation will vary by facility and patient.

1. Continuous SpO2 monitoring is recommended if available.

2. If continuous SpO2 monitoring is not available, we recommend checking SpO2 10
minutes after pronation to ensure stability. Although some patients will
temporarily have a slight worsening in vital signs immediately after pronation, HR,
BP, and SpO2 should return to close to baseline within 10 minutes. After the first
10 minutes, the interval of monitoring can be extended based on the clinical
context.

2. Telemetry: If telemetry is indicated, EKG leads can remain on anterior chest wall for
continuous monitoring, avoiding pressure points.

2. Prior to Proning

1. Make plans in advance for toileting, contacting nurses, and cellular phone if patient
has one.
2. If possible, place the bed in reverse Trendelenburg (head above feet, 10 degrees) to
help reduce intraocular pressure.
3. Have patient empty bladder.
4. Educate the patient.

1. Explain the procedure and rationale of the intervention to the patient. 

2. Point out any IV tubing or oxygen tubing they are connected to. Remind them this
tubing should not be under them at any time.
3. Instruct patient to roll back over and call for help if they feel worse.

5. Arrange tubing to travel towards the top of the bed, not across the patient, to
minimize risk of dislodging. Ensure support devices are well-secured to the patient.
(Eg. sleeve over IV access site, position urinary catheter)
6. Assess pressure areas to avoid skin breakdown and dress any wounds and use skin
protective devices as needed.
7. If the patient will require assistance, assess the patient’s size and weight to determine
adequacy of the bed frame and the mattress in addition to the number of staff
required to safely turn the patient.

3. Prone Position

1. The patient should lay on their abdomen (arms at sides or in “swimmer” position).  If
this is not a tolerable position, they can try laying on their side, though this may not
work as well (Bentley et al).
1. Show the patient how to choose which side to roll to so that they avoid any IV
tubing and how to adjust oxygen delivery device and pillows as needed

2. If a patient is unable to tolerate, they may rotate to lateral decubitus or partially prop
to the side (in between proning and lateral decubitus) using pillows or waffle
cushioning as needed. Ideally the patient should be fully proned rather than on the
side as there is currently no data about whether side positioning is beneficial.

4. Time Spent Proning

1. Patient should try proning every 4 hrs and overnight, and stay proned as long as
tolerated (ideally at least 30 minutes). Our ideal goal is 16 hrs per 24 hours (e.g. 4
times for 4 hours each session) based on common interpretations of the PROSEVA
trial (Guerin). However, we realize that few (if any) patients will tolerate 16 hrs of
proning per 24 hrs.

1. Perform range of motion or repositioning of arms and legs every 2 hours

5. When to Stop Proning

1. We recommend continuing daily cycles of proning until the patient is on nasal cannula
(<4 L/min) with SpO2>92%. The patient may choose to stop self-proning at any time
2. Stop proning if any of the following occur:

1. Patient intolerance. Do not administer sedation to facilitate proning.

2. Inability to maintain SpO2 > 87% or escalating oxygen requirements concerning for
potential need for intubation
3. Development of hemodynamic instability (BP < 90/50 or HR > 140 in an adult)

6. Assisted Proning as a Rescue Therapy

1. Assisted/rescue proning can be used in situations where a patient is unable to

position on their own and oxygen is unavailable or a patient is on the highest available
level of oxygen. In these situations, the benefits of proning may outweigh the risks.
2. The risks and benefits of assisted/rescue proning should be reassessed on a regular
basis. For instance, if there is no improvement and/or close monitoring is not
possible, supination may be considered in order to avoid complications (e.g. pressure
ulcers). If the patient has improved but frequent monitoring is not possible, the team
should discuss the risks and benefits of maintaining a prone position.
3. Reposition the patient’s arms every two hours
4. Perform range of motion to arms and legs every 2 hours
5. Assess the skin frequently for areas of non-blanchable redness or breakdown, with
special attention to the nose