CASE REPORT  NON-INVASIVE RESPIRATORY SUPPORT IN COVID-19 PNEUMONIA Open access

Italian Journal of Emergency Medicine 2021 December;10(3):150-2

DOI: 10.23736/S2532-1285.21.00122-1

Copyright © 2021 THE AUTHORS

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language: English

Non-invasive respiratory support in COVID-19 pneumonia: how to do it

Roberto COSENTINI ¹ ✉, Rodolfo FERRARI ², Anna M. BRAMBILLA ³, Paolo GROFF ⁴

¹ High Specialization Emergency (EAS), ASST Papa Giovanni XXIII, Bergamo, Italy; ² First Aid and Emergency Medicine Department, S. Maria della Scaletta Hospital, Imola, Bologna, Italy; ³ First Aid and Emergency Medicine Department, ASST Fatebenefratelli-Sacco, Sacco University Hospital, Milan, Italy; ⁴ First Aid and Emergency Medicine Department, Hospital of Perugia, Perugia, Italy

In this paper, the clinical scenario of a patient presenting in the ED with COVID-19 pneumonia is described step-by-step through the oxygen escalation pathway. For each step, indication, initial setting, and clinical failure criteria are provided: 1) step 1 (oxygen treatment - escalation from nasal prongs to Venturi mask to non-rebreathing mask, in order to achieve a target SO2 of 92-94%); 2) step 2 (high-flow nasal cannula oxygenation - start with flow at 50 L/min, temperature 34°C and adjust FiO2 according to the SO2 target); 3) step 3 (CPAP -start with PEEP 5 cmH2O and titrate FiO2 to the SO2 target); 4) step 4 (NIPPV - start with PEEP 5 cmH2O and pressure support of 10 cmH2O titrated to reach a target exhaled tidal volume of 4-6 mL/kg [IBW]); 4) from step 1-4 (awake self-repositioning/pronation - encourage patients to change his/her body position lying on one lateral side, then in the prone position with his chest upon a pillow, and finally to the other lateral side, monitoring vitals and SpO2 to see whether SpO2 rises to the target value of 92-94%. Successful position should be maintained for at least 2 hours). Finally, identify early NIPPV failure in clinical (anxiety, confusion, increased work of breathing, respiratory distress) and/or ABG terms (pO2, pH and pCO2), since delayed intubation worsens our patients’ prognosis.

KEY WORDS: COVID-19; Oxygen inhalation therapy; Continuous positive airway pressure; Pronation