Reviews

The optimal management of the patient with COVID‑19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation?

A G B Broadhurst, C Botha, G Calligaro, C Lee, U Lalla, C F N Koegelenberg, P D Gopalan, I A Joubert, G A Richards, B W Allwood

Abstract


Background. The recent pandemic has seen unprecedented demand for respiratory support of patients with COVID‑19 pneumonia, stretching services and clinicians. Yet despite the global numbers of patients treated, guidance is not clear on the correct choice of modality or the timing of escalation of therapy for an individual patient. This narrative review assesses the available literature on the best use of different modalities of respiratory support for an individual patient, and discusses benefits and risks of each, coupled with practical advice to improve outcomes. On current data, in an ideal context, it appears that as disease severity worsens, conventional oxygen therapy is not sufficient alone. In more severe disease, i.e. PaO2 /FiO2 ratios below approximately 200, helmet-CPAP (continuous positive airway pressure) (although not widely available) may be superior to high-flow nasal cannula (HFNC) therapy or facemask non-invasive ventilation (NIV)/CPAP, and that facemask NIV/CPAP may be superior to HFNC, but with noted important complications, including risk of pneumothoraces. In an ideal context, invasive mechanical ventilation should not be delayed where indicated and available. Vitally, the choice of respiratory support should not be prescriptive but contextualised to each setting, as supply and demand of resources vary markedly between institutions. Over time, institutions should develop clear policies to guide clinicians before demand exceeds supply, and should frequently review best practice as evidence matures

Authors' affiliations

A G B Broadhurst, Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

C Botha, Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

G Calligaro, Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa

C Lee, Discipline of Internal Medicine, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Grey’s Hospital, Pietermaritzburg, South Africa

U Lalla, Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

C F N Koegelenberg, Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

P D Gopalan, Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

I A Joubert, Department of Anaesthesia and Peri-operative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

G A Richards, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

B W Allwood, Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

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Cite this article

African Journal of Thoracic and Critical Care Medicine 2022;28(3):119-128.

Article History

Date submitted: 2022-09-16
Date published: 2022-09-16

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African Journal of Thoracic and Critical Care Medicine| Online ISSN: 2617-0205

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