Table 4

Recommendations on use of high flow nasal oxygen (HFNO) and non-invasive ventilation (NIV) in covid-19 from clinical guidelines available early in pandemic

GuidelineRecommendations
World Health Organization9High flow nasal oxygen and non-invasive ventilation should be used only in selected patients with hypoxaemic respiratory failure
Limited data suggest a high failure rate in patients with other viral infections such as MERS-CoV who receive NIV
Patients receiving a trial of NIV should be in a monitored setting and cared for by experienced personnel capable of endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hour). Patients with haemodynamic instability, multi-organ failure, or abnormal mental status should likely not receive NIV in place of other options such as invasive ventilation
Owing to uncertainty around the potential for aerosolisation, high flow oxygen and NIV, including bubble CPAP, should be used with airborne precautions until further evaluation of the safety can be completed
Ministry of Health, Brazil10Consider NIV if mild respiratory distress
Proceed with endotracheal intubation if there is no response to NIV using aerosol precautions
National Health Commission, China25Timely provision of effective oxygen therapy, including nasal catheter and mask oxygenation, and if necessary, nasal high flow oxygen therapy
When respiratory distress and/or hypoxaemia of the patient cannot be alleviated after receipt of standard oxygen therapy, high flow nasal cannula oxygen therapy or NIV can be considered. If conditions do not improve or even get worse within a short time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be used in a timely manner
COREB mission nationale, France11In general, techniques at risk of aerosolisation risk contamination of personnel and must be avoided as much as possible (NIV, HFNO)
In situations where NIV is still necessary, care givers must wear PPE and the patient must wear a mask. The NIV must be stopped before the mask is removed from the patient. Limit the presence of care givers in the rooms of infected patients receiving treatment with NIV or optiflow (HFNO)
Robert Koch Institute, Germany12Early administration of oxygen, possibly non-invasive or invasive ventilation
It is important to acknowledge that oxygen supplementation through high flow nasal cannula (HFNC) and NIV leads to aerosol formation. It is therefore absolutely necessary to make sure that HFNC and facemasks are fitted correctly to the patient, and that the medical personnel at the bedside strictly adhere to PPE instructions. NIV with a helmet should be preferred where available
In general, we advise medical professionals to be rather restrictive with HFNC and NIV in the context of covid-19. In patients with severe hypoxemia (PaO2/FiO2 ≤200 mm Hg) we suggest performing early intubation and invasive mechanical ventilation. In any case, continuous monitoring and preparedness for urgent intubation are cornerstones in the treatment of patients with covid-19 with respiratory failure. A delay in intubation in patients failing NIV worsens outcome, and any emergency intubation in this cohort puts medical professionals at risk and should be avoided
Ministry of Health, Holland26No specific guidance
Ministry of Health and Family Welfare, India14The risk of treatment failure is high in patients with MERS treated with NIV, and patients treated with either HFNO or NIV should be closely monitored for clinical deterioration
Recent publications suggest that newer HFNO and NIV systems with good interface fitting do not create widespread dispersion of exhaled air and therefore should be associated with low risk of airborne transmission
Ministry of Health, Indonesia13The use of NIV is not recommended in pandemic viral disease, because this causes delays in intubation, large tidal volume, and parenchymal injury. The available data, although limited, show the level of failure is high when MERS patients have oxygen therapy with NIV
Recent publications show that HFNO and NIV systems use an interface that matches the face so the risk of airborne transmission when patient expires is low
Società Italiana di Malattie Infettive e Tropicali, Italy15There is strong evidence that the use of NIV in the treatment of covid-19 pneumonia is associated with a worse outcome. On this basis, WHO recommends, where possible, avoidance of NIV and adoption instead of standards that provide for early intubation. If NIV is used, this must be done within an intensive care unit
Japanese Association of Infectious Diseases, Japan16No specific guidance
Department of Public Health, Malaysia17No specific guidance
Working group on COVID 2019, Russia18It is permissible to use NIV as the beginning of respiratory support in patients with acute respiratory distress
With the ineffectiveness of NIV—hypoxaemia, metabolic acidosis or no increase in the PaO2/FiO2 index in 2 hours, high breathing (desynchronisation with a respirator, participation of auxiliary muscles, “failures” during triggering of inspiration on pressure-time curve)—tracheal intubation is indicated
Centre for Disease Control, Saudi Arabia19No specific guidance; refers to WHO
Central COVID Task Force, South Korea20No specific guidance
Ministry of Health, Spain21HFNO and NIV should be reserved for very specific patients. NIV should under no circumstances delay the indication of intubation. Treatment failure with NIV in MERS was high. Patients with NIV and HFNO should be closely monitored and prepared for possible intubation
Center for Disease Control, Taiwan22Neither HFNO nor NIV is recommended for routine use in SARS-CoV-2 infected patients
According to the treatment experience of MERS patients, the treatment failure rate using NIV is high
Risks associated with NIV include delayed intubation, excessive tidal volume, injurious transpulmonary pressure, and haemodynamic instability
Ministry of Health, Turkey23No specific guidance
Centers for Disease Control and Prevention, USA24No specific guidance

CPAP=continuous positive airway pressure; MERS-CoV=Middle East respiratory syndrome coronavirus; PPE=personal protective equipment; SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.