Mechanical Ventilation & Pulmonary Vasodilators

  1. Guidelines/Recommendations

    1. Early intubation for patients with SpO2 < 92% or labored breathing on NRB facemask or high flow nasal cannula (see separate Airway Protocol)1

    2. Certain patients may benefit from a trial of high flow nasal cannula up to 30 L/min and 80% FiO2, but also require transfer to ICU for closer monitoring (See separate HFNC protocol)

    3. Target a deeper level of sedation (RASS -2 to -3) to prevent self-harm due to decreased bedside monitoring

    4. Strict adherence to lung protective ventilation (LPV)2 protocol, with following caveats:

      • Recommend initial trial of Standard PEEP due to observations of relatively preserved lung compliance in COVID-19 related ARDS3

            1. High PEEP may be beneficial if deteriorating lung compliance and refractory hypoxemia observed

      • Target higher PaO2/SpO2 to minimize need for ventilator changes

            1. PaO2 target 65-85 (instead of 55-80) mmHg (but minimize ABG’s)

            2. SpO2 target 92-96% (instead of 88-95%)

      • Target initial TV 6 ml/kg PBW per LPV protocol

            1. For stable patients, may allow TV up to 8 ml/kg PBW to improve synchrony as long as Pplat remains < 25 cmH20

    5. Strong consideration of early paralysis to achieve ventilator synchrony and minimize frequency of monitoring and staff exposure

    6. Application of Stanford Proning Protocol for patients with P/F < 150 on at least 0.70 FiO2 and at least PEEP 10 cmH20.

      • At least 4 people needed for proning and unproning (MD – attending or fellow; RT; and 2 nurses trained on protocol)

      • MD is anesthesia trained

      • Standard COVID-19 PPE required: N95 mask, face shield, gloves, and contact gown. CAPR not required

    7. Inhaled Nitric Oxide (iNO) use should be limited and reserved for patients with PaO2 < 60 mmHg or SpO2 < 90% on at least 0.80 FiO2, and after a trial of proning

      • Inhaled epoprostenol (Veletri) should be avoided on all COVID-19 patients due to need for more frequent breaks in circuit and more intensive management by respiratory therapists

    8. Vent Weaning: Due to observations of increased re-intubation rate and more involved airway management, consider longer spontaneous breathing trials and discuss with COVID airway team before extubation (see Intubation/Extubation guidelines)



  1. Rationale:

    1. Clinical descriptions of COVID-19 related pneumonia out of Wuhan, China describe a rapid deterioration to severe hypoxemia.

    2. In order to attenuate ventilator induced lung injury (VILI), we recommend adherence to the ARDSNet principle of lung protective ventilation.

    3. Anecdotally, COVID-19 patients have been described to, at least initially, not suffer from poor pulmonary compliance normally seen in ARDS (Gattinoni L, March 2020). For this reason, we recommend use of our LPV Low PEEP protocol, with flexibility to increase TV to 6-8 ml/kg PBW and higher threshold for initiating proning.



  1. References:

    1. Zuo MZ, Huang YG, Ma WH, et al. Expert Recommendations for Tracheal Intubation in Critically ill Patients with Novel Coronavirus Disease 2019. Chin Med Sci J. 2020 Feb 27.

    2. Brower RG, et al. Ventilation with Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome. NEJM. 2000; 342(18):1301-1308.

    3. Gattinoni L. Preliminary observations on the ventilatory management of ICU COVID-19 patients. Experience from Lombardy, Italy. Transcript; March 2020.



Respiratory Failure Guidelines (printer version)

Updated 3/24/2020

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