Algorithm for Noninvasive Respiratory Support Paths in COVID-19 Management

coronavirus disease 2019 covid lungs illustration
3D Rendering,COVID-19 virus infection of human lungs
A new algorithm offers guidance on when to start and stop noninvasive respiratory therapies for COVID-19.

A proposed algorithm for deciding at what points during the management of COVID-19 to initiate, stop, and/or wean patients from different noninvasive respiratory therapies (NIRTs) was outlined by researchers in an article published in Pulmonology.

Although data support the use of various NIRTs in the management of acute respiratory failure related to COVID-19, clinicians have lacked a full understanding of the optimal timing for using and withdrawing NIRTs, which include conventional oxygen therapy (COT), high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bi-level positive-pressure ventilation (BiPAP). An enhanced understanding of when and how to use these therapies is critical, given that recent data from the International Severe Acute Respiratory and Emerging Infections Consortium suggests that 15% of COVID-19 patients in the ICU have received CPAP or BiPAP and 14% have received HFNC.

The algorithm developed by researchers was based on an extensive review of current evidence on the use of NIRTs in COVID-19-related acute respiratory failure. Researchers developed a decision tree with interdependent steps as well as specific clinical criteria covering when and how to start, escalate, and re-evaluate use of COT, HFNC, CPAP, and BiPAP.

The algorithm also offered detailed criteria and decision-making guidance regarding initiation and use of NIV and directions regarding rotation of NIV/HFNC; intubation criteria after CPAP and NIV; guidance on NIV/HFNC after extubation; and criteria for HFNC discontinuation post-extubation.

Additionally, researchers addressed the utility of early NIRT as well as the merits of prone positioning as a measure that can “buy time” and possibly improve outcomes in patients with COVID-19-related respiratory distress. Current evidence suggests self-proning (ie, having alert patients roll themselves onto their stomachs or sides) can be used with COT, HFNC, mask CPAP, or helmet CPAP to increase oxygenation.

The authors said the proposed algorithm may aid decision-making among clinicians working in respiratory intermediate care units, as well as potentially decrease admission of patients with COVID-19 to overwhelmed intensive care units.


Winck JC, Scala R. Non-invasive respiratory support paths in hospitalized patients with COVID-19: proposal of an algorithm. Pulmonology. 2021;27(4):305-312. doi:10.1016/j.pulmoe.2020.12.005