Guías de práctica clínica COVID-19

Normalmente, se recomienda un enfoque escalonado:

  • Comenzando con HFNO (cuando el aerosol no es un problema)

  • Seguido por VMNI, y cuando no se observa un cambio rápido (1-2 horas)

  • Seguido por Ventilación Mecánica con intubación endotraqueal.

Las pautas de NHS (Reino Unido), LINK, son diferentes,

El uso de HFNO no se recomienda en pacientes con COVID-19 debido a la falta de eficacia, el uso de oxígeno y la propagación de infecciones.

 

Indicaciones para NIV (BiPAP para hipercapnia aguda en insuficiencia respiratoria crónica):

• como techo del tratamiento

• prueba para evitar la intubación

• para facilitar la extubación.

NIH (USA)

12 Mayo 2020, LINKRecomendaciones 

La HFNC y el VMNI son preferibles a la oxigenoterapia convencional basada en datos de ensayos clínicos y metaanálisis no COVID-19 que mostraron reducciones en la necesidad de escalada terapéutica y la necesidad de intubación. 

  • En ausencia de una indicación para la intubación endotraqueal, el Panel recomienda un ensayo controlado de cerca de NIPPV para adultos con COVID-19 y insuficiencia respiratoria hipoxémica aguda para quienes HFNC no está disponible.

ARIR (Italia)

LINK, Recomendaciones 

  • Ventilación no invasiva (VMNI): Sugerimos hacer un solo intento de soporte no invasivo por una duración máxima de 1 hora. Si no se observa una mejora sustancial, notifique al equipo y cambie al soporte apropiado (ventilación invasiva).

ITS , AIPO, SIP (Italia)

LINKRecomendaciones 

Dirección General de Salud Pública (España)

LINKRecomendaciones:

  • En la ventilación no invasiva (VNI), si es estrictamente necesaria su utilización, se debe lograr un sellado adecuado de las interfases para evitar las fugas, y emplear preferentemente VNI con doble tubuladura y filtro.

British Thoracic Society (UK)

LINKRecomendaciones:

Use of acute NIV in patients hospitalised with suspected or confirmed COVID-19 infection

 

In preparation for the peak in demand for acute non-invasive ventilation (NIV), outlined below are both strategic and operational guidance DELAY PHASE. This

guidance is relevant for all clinicians involved in delivering acute NIV services, including ward-based care.

16 March 2020

Masks

  • Well-fitting oronasal facemasks, masks over the total face, or helmets should produce least droplet dissemination.

  • Vented masks could worsen contamination of the environment

  • Any patient on acute NIV should be managed with a non-vented mask and

    an exhalation port in the circuit.

  • Ensure that the ventilator mode employed supports the use of non-vented

    masks and exhalation ports.

  • Sequence of actions: NIV mask on  ventilator on; ventilator off NIV mask off.

    Filters

  • A viral/bacterial filter should be placed in the circuit between the mask and the exhalation port (Figure below).

  • This viral/bacterial filter can replace any filter at the machine end of the circuit.

  • Viral/bacterial filters should ideally be changed every 24 hours or sooner. (There is a risk that they will become wet due to exhaled gas and that this may increase resistance to flow.)

  • An external humidifier must not be used.

  • Blocked filters can be mistaken for clinical deterioration; this issue is remedied by

    changing filters.

    Oxygen

• Oxygen can be entrained into the circuit and should be done so at the patient end.

  

For Patients already managed under home ventilation services who are admitted to hospital with suspected or confirmed COVID-19 infection

  • A viral/bacterial filter should be placed in between the mask and the

    exhalation port in exactly the same way as for acute NIV.

  • For any patient who has a humidifier in the community, the humidifier

    should be removed from the circuit.

  • Patients remaining at home should continue with their usual method of

    ventilation.

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