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Review Article

Oxygen Delivery Devices in Covid‑19 Patients: Review and

Recommendation
Avishek Roy, Abhishek Singh, Puneet Khanna
Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Abstract
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has become a matter of concern all over the world. This virus
caused acute respiratory distress syndrome(ARDS) in almost 67% of patients, with 71% of total patients requiring mechanical ventilation.
Oxygen therapy is prudent for patients suffering fromSARS-CoV-2 at different stages of the disease. The choice of different oxygen delivery
devices depends on the patient’s status and its availability. In this review we will discuss the pros and cons of several oxygen delivery devices,
as well as the safety precautions and personal protective equipments.

Keywords: Coronavirus pandemic, oxygen delivery devices, prevention of transmission

Introduction and upper airway during coughing, sneezing, and during

The severe acute respiratory syndrome coronavirus‑2
(SARS‑CoV‑2) pandemic has become a matter of concern
for general public and health‑care professionals. As per the
WHO, until March 24, 2020, among 2,549,632 confirmed
cases, this virus has led to the death of 175,825  patients.
Among 72,314 confirmed SARS‑CoV‑2 patients in China, 81%
had mild symptoms, nearly 14% develop severe symptoms
such as dyspnea and hypoxia, 5% became critically ill, and
1%–3% required intubation. [1] Among critically ill patients,
this virus caused acute respiratory distress syndrome (ARDS)
in almost 67% of patients, with 71% of total patients requiring
mechanical ventilation with a 28‑day mortality of 61.5%.[2]
Overall case fatality rate ranges between 2.3 and 7.2% among
various countries.[1]
Oxygen therapy is prudent for patients suffering from
SARS‑CoV‑2 at different stages of the disease. Oxygen
delivered through different devices creates different amounts
of aerosols and pose the threat of nosocomial infection to
health‑care workers (HCW) and other patients. Although the
exact definitions of droplets and aerosols are blurry, droplets
can be considered to be larger, causing a direct person‑to‑person
spread within close proximity, whereas aerosols are smaller
suspended infective particles causing airborne spread.[3,4]
Larger aerosols of size ≥10 µm are generated from the larynx
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aerosol‑generating procedures  (AGPs), such as intubation,
bronchoscopy, bag‑mask ventilation, and tracheotomy. [5]
Although the choice of different oxygen delivery devices
depends on the patient’s status and availability, their use has
to be weighed against their aerosol‑generating potential.
Here, we will discuss the pros and cons of different oxygen
delivery devices. All of the above procedures require safety
precautions, such as personal‑protective equipment (PPE) for
HCWs, negative pressure isolation rooms, proper donning,
and doffing areas.[6]
Low Flow and Low‑Performance Devices
Nasal cannula and nasal catheters and Blow over devices
The nasal cannula and catheters provide low to a moderate
Address for correspondence: Dr. Abhishek Singh,
AB8, Eight Floor, Main Building, Ansari Nagar East, New Delhi ‑ 110 029
India.
E‑mail: bikunrs77@gmail.com
Submitted: 26‑Apr‑2020 Revised: 14-Apr-2020
Accepted: 25-May-2020 Published: 13-Jul-2020
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Roy A, Singh A, Khanna P. Oxygen delivery
10.4103/BJOA.BJOA_62_20 devices in Covid-19 patients: Review and recommendation. Bali J
Anaesthesiol 2020;4:S3-7.

© 2020 Bali Journal of Anesthesiology | Published by Wolters Kluwer - Medknow S3

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Roy, et al.: Various methods and devices for oxygen therapy in Covid‑19 patients
fraction of inspired oxygen (FiO2) of 0.240.4 at oxygen flows
of 1–6 L/min, as higher flows are associated with nasal crusting
and irritation. The nasal cannula has the advantage that it can
be used with a face mask/N95 mask. Blow over devices are
made with the help of masks or paper drinking cups and are
used for infants and small children. They provide FiO2 < 0.3
at flows of at least 10 L/min.
Aerosol generation
All these devices produce aerosols. The nasal cannula can
cause the aerosol spread of up to 0.42 m laterally and up to
1 m toward the end of the bed. While in quiet patients, flows of
1 L/min cause aerosol spread up to 0.3 m, the distance increases
to 0.42 m in patients with respiratory distress requiring higher
flows of 5 L/min.[7] An aerosol spread can further increase to
0.8 m with coughing and sneezing.[8,6]
Recommendation
In mild‑to‑moderate symptomatic patients, nasal cannula and
blow over oxygen can be used at flows of 4–6 L/min, with the
patient’s face covered with N95 or equivalent face mask along
with other precautions applicable for AGPs.
Simple face mask and nebulizers
Simple Hudson facemask delivers FiO2 of 0.35–0.5 at flows
of 5–8 L/min and is used for the moderate duration of oxygen
therapy, for example, postanesthesia, after extubation in the
intensive care unit. Nebulizers function and form droplets of
different sizes to deliver the drugs. Depending on different
manufacturers, nebulizers generate the droplets of varying
sizes.
Aerosol generation
In normal quiet‑breathing patients requiring 4  L/min of
oxygen flows, a simple face mask may lead to the aerosol
spread of up to 0.2 m.[9] However, in sick patients requiring
flows ≥10 L/min, the maximal aerosol spread can occur beyond
0.4 m.[10,11] Simple face mask application can be difficult for
disoriented patients and with N95 respirators. With the advent
of this pandemic, nebulizers have to be used with caution.[12,13]
In human’s lung simulation study, jet nebulization caused
aerosol spread up to 0.45 m in normal healthy lungs, while in
severely injured lungs, aerosol spread occurred beyond 0.8 m.[7]
Patients who require nebulizers mostly have asthma, or chronic
obstructive pulmonary disease  (COPD) as the underlying
disease, and therefore, more likely to cough, which, combined
with high flows of jet nebulizer produces a huge number of
aerosols. Although debatable, nebulization with normal saline
may act to heat the air‑fluid interface of the airway and increase
droplet size thus decreasing the distance covered.[4]
Recommendation
Only in co‑operative patients with mild‑to‑moderate respiratory
distress, facemask can be used. Open nebulizers should be
avoided; rather a metered‑dose inhaler with spacer device or
manual in‑line nebulization should be used. Nebulization with
normal saline may be used to increase droplet size and thus
prevent distant spread of droplets.
S4
High Flow Devices, Reservoirs, and Noninvasive
Ventilation
Partial rebreathing mask, nonrebreathing mask, and
venturi mask
All require higher flows of at least 10 L/min. Partial rebreathing
mask having a reservoir bag leads to some air entrainment
and can deliver FiO 2 of 0.4–0.7 at 10–15  L/min flows.
Nonrebreathing masks (NRMs) have an additional one‑way
valve that prevents room air entrainment and rebreathing of
exhaled gases. It can deliver FiO2 above 0.8, provided there
is a good mask fit, and airflow is more than three times of
minute ventilation. Venturi masks  (VM) blend oxygen and
room air depending on the desired FiO2 but require moderate
to high flows.
Aerosol generation
With a tight‑fitting mask, the aerosol spread is only about 0.1 m
for NRMs. VMs generate aerosol up to 0.4 m at desired FiO2
of 0.24 and up to 0.33 m at desired FiO2 of 0.4.[7] Exhalation
filters can be used to curtail the spread of aerosols in above
methods.[9]
Recommendation
Rebreathing masks can be used to provide moderate‑to‑high
FiO2 for moderate duration, e.g., before intubation
and postextubation. NRMs are the preferred mode for
preoxygenation before intubation. VMs can be used to provide
lower and fixed FiO2. Nasal cannula combined with NRM can
be used to provide higher FiO2.[14]
High‑flow nasal cannula and OxyMask
High‑flow nasal cannula  (HFNC) provides heated
humidified oxygen at flows from 10  L/min up to
50  L/min. At high flows, it provides positive pressure.
It has been used in the conditions such as respiratory
distress, preoxygenation, and apneic diffusion of oxygen
in airway procedures, in both adult and pediatric age
groups. [15] A combination of HFNC and noninvasive
ventilation (NIV) mask has shown to reduce re‑intubation
rates at day 7 postextubation in critically ill patients, as
compared to high‑flow nasal oxygen alone.[16] Using HFNC
interchangeably with NIV can also reduce the patient’s
discomfort as compared to using NIV alone.[17] Although
widely used in patients suffering from SARS‑CoV‑2
pneumonia, around 41% of patients with PaO2/FiO2 (P/F)
ratio  ≤200  mmHg had failure with HFNC therapy and
required either NIV or intubation.[18] OxyMask is a specially
designed mask used to provide higher FiO2, although initial
studies showed its superior efficacy as compared to HFNC,
this notion has been questioned, as flows above 20 L/min
haven’t shown to increase FiO2.[14]
Aerosol generation
By increasing the flows from 10 L/min to 60 L/min, HFNC
has shown to increase aerosol spread from 65 to 172 mm in the
sagittal plane. It can also cause air leakage around the mask up
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Roy, et al.: Various methods and devices for oxygen therapy in Covid‑19 patients
to 620 mm.[19] Some recommend avoiding the use of HFNC.[20]
Aerosol dispersion can be lessened using a surgical mask and
asking patients to breathe through nose with mouth closed.[17]
In a human patient‑simulator model, use of a surgical mask
during normal cough reduced aerosol spread from 68 cm to
30 cm, and further reduction of diffusion distance was noted
with the use of N95 mask.[8]
Recommendation
HFNC can be used to provide oxygen, preferably in patients
with acute respiratory failure with P/F ratio ≥200 mm Hg. It
should be ensured that the nasal reservoir used with HFNC is
snugly fit, and the patients are instructed to wear surgical/N95
masks and breathe nasally. OxyMask should be used at
flows ≤20 L/min.
Noninvasive ventilation
Both Continuous positive airway pressure (CPAP) and Bilevel
positive airway pressure (BiPAP) have been used for the acute
exacerbation of COPD (AECOPD) and acute congestive heart
failure (ACHF). Patients with a P/F ratio of 100–200 mm Hg
and sequential organ failure assessment score ≤2 should be
treated with BiPAP therapy with some modifications. Those
patients in whom HFNC therapy failed, NIV caused an
increase in P/F ratio and a decrease in respiratory rate; thus,
alleviating intubation.[18] However, in severely symptomatic
patients with viral pneumonia, its use is limited as it may only
delay intubation and lead to mortality.[2] Furthermore, the lack
of properly fitting masks and accessories preclude the use of
NIV in many settings.[21]
Aerosol generation
CPAP of 5–10 cm H2O may lead to aerosol generation up to
332 mm depending on different manufacturers.[19] NIV generates
aerosols of more than 10 µm diameter, especially in patients
with symptoms.[13] With increasing inspiratory pressures, BiPAP
leads to significant aerosol generation. At constant expiratory
pressures of 4 cm H2O, increasing inspiratory pressures from
10 cm to 18 cm H2O increases aerosol spread from 0.65 m to
0.85 m. Whisper swivel adapter, a one‑way valve to prevent
rebreathing, further increases aerosol spread beyond 1 m.[13] In
comparison to oral/nasal masks, the use of a helmet for NIV
can curtail the aerosol spread.[22] Adequate precautions should
be taken before applying NIV.[23]
Recommendation
NIV can be used in the conditions such as cooperative patients
with AECOPD or ACHF due to COVID infection, taking all
precautions related to the airborne spread. Inspiratory pressures
should be kept at a minimum level, preferably ≤10 cm H2O. Air
leak should be minimized by the use of snuggle‑fitting masks
or helmet. Whisper swivel adapter and vented masks should
be avoided. Breathing circuits should be used with exhalation
port high‑efficiency particulate (HEPA) filters. In addition to
the above devices, chest physiotherapy and compression can
lead to droplet generation of size ≥10 µm, and thus, should
be avoided in the absence of adequate health precautions.[7]
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Bag‑Mask Ventilation, Supraglottic Devices, and
Intubation
Bag‑mask ventilation  (BMV) is done before intubation,
especially in apneic patients. The use of supraglottic devices
is still being advocated in difficult airway scenarios.[20,24]
Although there are no specific guidelines for intubation
in SARS‑CoV‑2  patients, keeping a low threshold for
intubation is advised. Intubation is generally advised in
the following scenarios: rapid progression over hours, lack
of improvement with noninvasive methods, hypercapnia,
hemodynamic instability or multiorgan dysfunction, and
altered neutrophil‑lymphocyte ratio.[25] As much as 1%–3% of
total infected cases and 15% of total patients requiring some
form of oxygen therapy were intubated.[1,18]
Aerosol generation
Bag and mask ventilation, as well as intubation, leads to the
generation of significant amounts of aerosols. Intubation
has the highest hazard ratio for aerosol spread to HCWs.
Other intubation‑associated procedures such as placement
of nasogastric tube have a lesser chance of aerosol spread.[5]
Supraglottic devices should be preferred to BMV to provide
positive pressure ventilation as they generate lesser aerosols as
compared to BMV.[20] Experienced personnel is less likely to
spread aerosols during the airway management. Other modalities
such as providing continuous suction rather than intermittent
suction, administration of sedatives or paralytic agents to reduce
cough in patients, have shown to reduce aerosol spread.[26]
Recommendation
For lessening aerosol spread during intubation and mechanical
ventilation, methods such as head‑up position, rapid sequence
induction, use nonrebreathing masks for preoxygenation, use
of supraglottic devices instead of BMV for positive pressure
ventilation, minimizing ventilator disconnections, use of
in‑line suction and nebulization, ensuring proper cuff seal,
using two HEPA/heat moist exchanger filters, for example, one
between Y‑piece and patient end and another at the expiratory
port, decreasing number of machine checks and change of
suction tubing, should be advocated. During extubation,
applying lignocaine jelly over the cuff of an endotracheal tube
or covering a wet‑gauge piece over the patient’s mouth might
decrease aerosol spread. Extubation should only be done only
when the viral load has decreased, and the risk of aerosol spread
is minimized. Flush of any kind should be avoided.
In the absence of NIV with closed circuit and NRMs, gentle bag
and mask ventilation with low‑tidal volume, using both thenar
prominence to create a good seal and using two filters, can
significantly reduce aerosol spread as well as recontamination.
Conclusion
Oxygen therapy is a major pillar in treating patients suffering
from SARS‑CoV‑2 infection. The use of individual oxygen
delivery methods should be tailored to individual patient needs,
their availability. Table  1 shows the maximum exhaled air
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Roy, et al.: Various methods and devices for oxygen therapy in Covid‑19 patients

Table 1: Different oxygen delivery devices and aerosol generation

Classification Individual devices FiO2 Aerosol spread by distance Use
Low flow Nasal cannula 0.24‑0.4 ++ (increases with cough and sneeze) At flows 4‑6 l/m, with facemask
devices Blow over <0.3 ++, + Flows higher ≥10 l/m, low performance device only
used for children
Simple Hudson <0.35‑0.5 ++ Additional (, ++) Significant leak around the mask; proper fitting
facemask±nebulizer +++++ (nebulizer) important; open nebulization avoided
High flow PRM and NRM 0.35‑>0.8 ++ (PRM) NRM should be used wherever possible especially
devices and + (NRM) preoxygenation
reservoirs HFNC >0.8 +++ Proper fitting important; to be used with surgical mask
OxyMask 0.4‑0.8 +++ Higher flows beyond 20 l/min avoided
NIV >0.8 +++ Should be avoided wherever possible/used with lower
+++++ (swivel adapter/higher inspiratory pressures; with exhalation valve
inspiratory pressure)
Mechanical BMV Up to 1.0 +++++ Avoided/used with lower‑tidal volume, good mask
ventilation seal, and two filters
Int intubation Any FiO2 +++++ (during intubation) Avoid circuit disconnection, open suctioning; ensure
+‑‑ (during ventilation) proper cuff seal, use close suctioning
+ indicates aerosol dispersion properties. The increase in + denotes more severe dispersion. +- indicates negligible or no aerosol dispersion. FiO2: Fraction
of inspired oxygen, PRM: Partial rebreathing mask, NRM: Nonrebreathing mask, NIV: Noninvasive ventilation, BMV: Bag‑mask ventilation, HFNC:
High‑flow nasal cannula

Financial support and sponsorship

Nil.
Conflicts of interest
There are no conflicts of interest.

Figure 1: Flow diagram showing choice of oxygen delivery devices
dispersion distance through different oxygen administration and
ventilatory support strategies. Figure 1 throws some light on how
to choose appropriate oxygen delivery devices depending on
the patient’s clinical condition. Although the aerosol‑generating
potential poses a threat to HCWs, their use is indispensable in
low‑resource setup where ICU beds and ventilators are limited in
number. In selected patients, by reducing the work of breathing,
these devices might alleviate the need for ventilators and possibly
lead to lesser aerosol generation due to the reduction in flow
requirements.[18] Even in patients ARDS, prone positioning along
with NIV/HFNC has been found useful.[27]
Nonetheless, proper single patient negative pressure isolation
room, along with the provision of adequate PPEs for HCWs
and other methods of preventing viral spread, is of utmost
importance.
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