Global Current Practices of Ventilatory Support Management in COVID-19 Patients: An International Survey

Figures & data

Table 1 Characteristics of Critical Care Practitioners (N= 502) *

Characteristics	Values
Highest qualification
● Diploma	45 (8.96%)
● Bachelor	228 (45.42%)
● Master	158 (31.47%)
● PhD	71 (14.14%)
Profession
● Respiratory therapists	173 (34.46%)
● Physiotherapist	123 (24.50%)
● Nurse	8 (1.59%)
● ICU Intensivist	108 (21.51%)
● Pulmonologist	60 (11.95%)
● Anesthesiologist	30 (5.98%)
Continent
● Africa	4 (0.80%)
● Asia	185 (36.85%)
● Europe	159 (31.67%)
● North America	36 (7.17%)
● Oceania	6 (1.20%)
● South America	112 (22.31%)
Type of hospital
● Secondary care hospital	137 (27.29%)
● Tertiary care hospital	365 (72.71%)
Hospital characteristics
● <200 beds	93 (19.02%)
● 200–499 beds	175 (35.79%)
● 500–1000 beds	141 (28.83%)
● >1000 beds	80 (16.36%)
ICU beds
● Total number	31,144
● Mean (±SD)	64 (±84)
● 1–10	42 (8.64%)
● 11–100	365 (75.10%)
● >100	79 (16.26%)
Previous training in MV	424 (85%)
Experience and training
● >20 – year experience	94 (18.73%)
● 11–20 – year experience	144 (28.69%)
● 6–10 – year experience	115 (22.91%)
● ≤5 – year experience	149 (29.68%)
● >20 – year experience and trained	82 (19%)
● 11–20 – year experience and trained	122 (29%)
● 6–10 – year experience and trained	97 (23%)
● ≤5 – year experience and trained	123 (29%)

Note: *All percentages are expressed corresponding to the total number of respondents.

Abbreviations: PhD, Doctor of Philosophy; ICU, intensive care unit; SD, standard deviation.

Figure 1 Percentage of responders per country.

Figure 2 Academic degrees per continent.

Figure 3 Formal training in MV per continent.

Figure 4 Mean ICU beds per continent.

Figure 5 Total beds per hospital in all continents.

Table 2 Factors Considered in the Clinical Management of COVID-19 Patients and the Maintenance of Ventilators (N= 502)*

Characteristics	Values
Initial diagnostic tool used for therapy initiation
● Arterial Blood Gas	241 (48%)
● Chest Imaging	42 (8.4%)
● Clinical Presentation	188 (37.5%)
● All of the Above	31 (6.2%)
Available protocols
● HFNC	195 (38.8%)
● NIV	284 (56.6%)
● IMV	416 (82.9%)
Used COVID-19 guidelines
● Own practice	197 (39.2%)
● National	307 (61.2%)
● WHO	239 (47.6%)
● AARC	128 (25.5%)
● NICE	63 (12.5%)
● ANZICS	29 (5.8%)
● SCCM	197 (39.2%)
Initial ventilation strategy based on severity
MILD
HFNC	270 (53.8%)
NIV	123 (24.5%)
IMV	24 (4.8%)
Moderate
HFNC	87 (17.3%)
NIV	236 (47%)
IMV	130 (25.9%)
SEVERE
HFNC	5 (1%)
NIV	15 (3%)
IMV	462 (92%)
Ventilator management
Suctioning system used
Open	35 (7%)
Closed	467 (93%)
Ventilator system check
As needed	270 (53.8%)
Every 1–2 hours	53 (10.6%)
Every 2 hours	67 (13.3%)
Every 4 hours	112 (22.3%)

Note: *All percentages are expressed corresponding to the total number of respondents.

Abbreviations: AARC, American Association for Respiratory Care; ANZICS, Australian and New Zealand Intensive Care Society; HFNC, high flow nasal cannula; IMV, invasive mechanical ventilation; NICE, National Institute for Health and Care Excellence; NIV, noninvasive ventilation; SCCM, Society of Critical Care Medicine; WHO, World health Organization.

Table 3 General Management of COVID-19 Using Ventilatory Support (N= 502)*

Characteristics	Values
Initial flow setting of HFNC
● Below 30 L/m	90 (17.9%)
● From 30 to 45 L/m	150 (29.9%)
● More than 45 L/m	80 (15.9%)
Use of humidification with HFNC	309 (61.6%)
NIV modes
BiPAP	161 (32.1%)
CPAP/PS	204 (40.6%)
PC	43 (8.6%)
VC	19 (3.8%)
NIV interfaces frequently used
Full face mask	192 (38.2%)
Helmet	67 (13.3%)
Nasal mask	19 (3.8%)
Oronasal mask	154 (30.7%)
IMV modes
● APRV	39 (7.8%)
● PC	175 (34.9%)
● PRVC	107 (21.3%)
● VC	181 (36.1%)
Humidifier type used with IMV
● Heated circuit	135 (26.9%)
● HEPA	11 (2.2%)
● HME	356 (70.9%)
Ventilation strategy used in IMV
● Low VT ventilation (VT: 4–8 ml/kg of predicted body)	481 (96%)
● Higher VT ventilation (VT>8 ml/kg of predicted body weigh)	20 (4%)
PEEP strategy
● Lower PEEP (PEEP levels <10 cm H2O)	182 (36.3%)
● Higher PEEP (PEEP levels >10 cm H2O)	320 (63.7%)
Use of prone with IMV	430 (85.7%)
Prone duration
<12 hours/day	74 (14.7%)
12 to 16 hours/day	243 (48.4%)
● >16 hours/day	116 (23.1%)
Reasons for not proning
● Limited resources	61 (12.2%)
● Lack of staff training	71 (14.9%)
● Complications	67 (13.3%)
● Not indicated	64 (12.7%)
Tried awake prone positioning	232 (46.2%)
Frequent use of nitric oxide	61 (12.2%)
Use inhaled pulmonary vasodilator	191 (38%)
Use of recruitment manoeuvres	349 (69.5%)
Recruitment manoeuvres used
● Stepwise PEEP adjustment	214 (42.6%)
● Inspiratory hold	146 (29.1%)
Use of (VV) ECMO	97 (19.3%)
Use of systemic corticosteroids	323 (64.3%)

Note: *All percentages are expressed corresponding to the total number of respondents.

Abbreviations: APRV, airway pressure release ventilation; BIPAP, bilevel positive airway pressure; CPAP/PS, continuous positive airway pressure/pressure support; HME, heat and moisture exchanger; HEPA, high-efficiency particulate air; PEEP, positive end-expiratory pressure; PC, pressure control; PRVC, pressure regulated volume control; Vt, tidal volume; VV, venovenous; VC, volume control.

Figure 6 Barriers and limitations of COVID-19 clinical management. (A) represents the (%) of barriers and limitations per continent. (B) represents the (%) of barriers and limitations corresponding to the overall responses.