Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

Prashant Nasa, Elie Azoulay, Ashish K. Khanna, Ravi Jain, Sachin Gupta, Yash Javeri, Deven Juneja, Pradeep Rangappa, Krishnaswamy Sundararajan, Waleed Alhazzani, Massimo Antonelli, Yaseen M. Arabi, Jan Bakker, Laurent J. Brochard, Adam M. Deane, Bin Du, Sharon Einav, Andrés Esteban, Ognjen Gajic, Samuel M. GalvagnoClaude Guérin, Samir Jaber, Gopi C. Khilnani, Younsuck Koh, Jean Baptiste Lascarrou, Flavia R. Machado, Manu L.N.G. Malbrain, Jordi Mancebo, Michael T. McCurdy, Brendan A. McGrath, Sangeeta Mehta, Armand Mekontso-Dessap, Mervyn Mer, Michael Nurok, Pauline K. Park, Paolo Pelosi, John V. Peter, Jason Phua, David V. Pilcher, Lise Piquilloud, Peter Schellongowski, Marcus J. Schultz, Manu Shankar-Hari, Suveer Singh, Massimiliano Sorbello, Ravindranath Tiruvoipati, Andrew A. Udy, Tobias Welte, Sheila N. Myatra

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods: Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). Results: Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion: Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical Identifier: NCT04534569.

Original languageEnglish (US)
Article number106
JournalCritical Care
Issue number1
StatePublished - Dec 2021


  • COVID 19 invasive mechanical ventilation
  • COVID-19 acute respiratory distress syndrome
  • COVID-19 high flow nasal oxygen
  • COVID-19 respiratory management
  • COVID-19 ventilatory management
  • Respiratory distress syndrome adult

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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