As we know COVID-19 is putan incredible burden on resources, especially for higher level respiratory support. It is important to target those resources in the most effect way. Currently we are targeting SaO2 >94% in those without type 2 respiratory failure(however, in the case of high demand this may reduce to 92% at short notice in the future)

	HRI	CRH
CPAP/NIV	HDU/ICU	HDU/ICU
Oxygen ONLY (FOR Escalation)	Acute Floor	Respiratory/Acute Floor
Oxygen ONLY (NOT FOR Escalation)	Acute Floor/Ward 17	Respiratory/Acute Floor/Ward 6CD
Palliative	Ward 6	Ward 6AB

Awake Proning

We are getting more evidence/experience from centres that proning awake patients while awake either on oxygen masks or CPAP, can drastically improve oxygenation (Hence inclusion into the flow chart). MORE Info…

Proning can: Help recruit larger areas of the lung, by reducing lung compression, improve ventilation and help clear secretions

CPAP/NIV/HFNO

• CPAP/NIV: has increasing evidence for its use, it is potentially a useful holding measure as a bridge to ICU , and may represent the ceiling of care for many of our patients. However,  it is not a panacea and needs careful review.
  • Start with a PEEP of 10cmH2O
  • Review @ 2hrs – patients who are deteriorating  need to be either intubated or palliated
  • Review @ 6hrs if continuing – This will be  hard as those not improving will likely need to be stepped down, there is increasing evidence that those that are “just managing” in CPAP and continue for days are developing significant lung damage, and failing.
• HFNO (High Flow Nasal Oxygen): We are not recommending this for several reasons
  • It doesn’t supply much PEEP – not as effective as CPAP/NIV
  • It produces lots of Aerosol –  dangerous for staff
  • It uses lots of Oxygen – we can only provide 3000l/min across the hospital (use of HFNO will deny oxygen to others)

Escalation Decisions

This is difficult for us all, but is something we need to do early. As unfortunately there are no magic bullets, mortality for patients requiring ventilatory support through any modality is high.

The 4C morality score has been developed by ISARIC, on UK Covid-19 patient information, and is a useful tool.

• • 4C Factors include: Age, Sex, Co-morbidities, RR, Sats, Urea and CRP

Other things to think about:

• Clinical Frailty Scale (esp. if 5 OR more)
• Co-Morbidities (Cardiovascular, COPD, Dementia, Diabetes, Malignancy)
• Age (esp. over 80yrs, but poor outcomes seen in the over 65yrs)
• Pre-Morbid exercise tolerance

Decisions can be difficult but it is important we make them. Escalate early to seniors for support