Respiratory Failure Treatment of the COVID/PUI Patient

reviewed Feb. 2021

COVID O2 sat
patient <90%?

yes no

NC Consider Start/titrate regular NC

>6L/m? iNO for SpO2 90-96%

yes no

Consider
consult for HFNC at:
transfer to ICU Re-assess regularly
• 30-40L/m and
for decompensation
team • FiO2 100%
Titrate HFNC for
Start HFNC at SpO2 90-96%
FiO 50% & Encourage
30L/mǁ proning (for no yes
sleep & 3-6h at a
Check time during day)
ABG in Consider trial of NIPPV
30-60m if (1) think can rapidly
P/F* ≥150 or Start/titrate ARDSNet
reverse or (2) needs
SpO2/FiO2† protocol LTVV using low PEEP
only short durationǁ
≥190 table for goal:§
• PaO2>55 or SpO2>88% &
• pH>7.20
yes no
Able to
come off
Target Target Intubate using for ≥60min
RASS RASS -5 ± steps to minimize breaks?**
-2 to -3‡ paralysis risk of exposure
(see SOP) no yes

P/F* ≥150 or Start P/F* ≥150 or

SpO2/FiO2† proning via SpO2/FiO2†
≥190 protocol ≥190
yes no yes no

ǁ consult ICU at initiation of HFNC or NIPPV if patient not do-not-intubate status Consider ECMO
* With PEEP≥5 cmH2O in select cases
† S/F 190 = P/F 150 using formula from Rice TW et al, Chest 2007
‡ if tolerating well & synchronous with ventilator, consider RASS 0 to -1
§ may consider liberalized tidal volumes to 8cc/kg PBW & lower PEEP if good compliance & ↑ academia
** have heightened concern if requiring NIPPV for >2 hours (other than overnight for known apnea) & strongly consider intubation