Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method
Authors: Nasa Prashant , Azoulay Elie , Khanna Ashish K. , Jain Ravi , Gupta Sachin , Javeri Yash , Juneja Deven , Rangappa Pradeep , Sundararajan Krishnaswamy , Alhazzani Waleed , Antonelli Massimo , Arabi Yaseen M. , Bakker Jan , Brochard Laurent J. , Deane Adam M. , Du Bin , Einav Sharon , Esteban Andrés , Gajic Ognjen , Galvagno Samuel M. , Guérin Claude , Jaber Samir , Khilnani Gopi C. , Koh Younsuck , Lascarrou Jean-Baptiste , Machado Flavia R. , Malbrain Manu L. N. G. , Mancebo Jordi , McCurdy Michael T. , McGrath Brendan A. , Mehta Sangeeta , Mekontso-Dessap Armand , Mer Mervyn , Nurok Michael , Park Pauline K. , Pelosi Paolo , Peter John V. , Phua Jason , Pilcher David V. , Piquilloud Lise , Schellongowski Peter , Schultz Marcus J. , Shankar-Hari Manu , Singh Suveer , Sorbello Massimiliano , Tiruvoipati Ravindranath , Udy Andrew A. , Welte Tobias , Myatra Sheila N. 
Published: March 2021

Abstract
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 trials.gov Identifier: NCT04534569.