General Respiratory Care

Patients With or Under Investigation for COVID-19


  • Patients with COVID-19 respiratory disease require a spectrum of respiratory care ranging from:

    • Oxygen therapy via nasal cannula (NC)

    • Oxygen therapy via high flow nasal cannula (HFNC)

    • Oxygen therapy via non-rebreather mask (NRB)

    • Invasive mechanical ventilation (IMV)

    • Pulmonary toilet

    • Inhaled bronchodilator or corticosteroid therapy

    • Lower respiratory tract suctioning – therapeutic & diagnostic (mini-BAL)

    • Flexible bronchoscopy (rare)

  • Based on available data, we expect that approximately 50% patients admitted to the ICU will have moderate pulmonary disease managed with supplemental NC alone, and 50% will have severe disease requiring invasive mechanical ventilation

  • Veterans are especially vulnerable due to the high prevalence of chronic pulmonary diseases which may become unstable during COVID-19 infection


Isolation of Patients with COVID-19

  • Patients on nasal cannula (≤ 6 L/min) should have a droplet mask placed over their nose and mouth

  • Patients who are intubated will have a combination HME/Viral filter placed in the expiratory limb of their ventilator circuit.

  • Aerosol-generative procedures should be performed in a negative pressure airborne isolation room in the SICU














Oxygen Delivery

  • Nasal Cannula (NC) Oxygen

    • Oxygen delivered between 1 – 6 L/min to keep SpO2 at 90 – 92%. This lower saturation target will facilitate early detection of worsening oxygenation, since oxyhemoglobin curve is steepest in this range


  • Oxygen Therapy via HFNC

    • Oxygen delivered between 15 – 30 L/min to keep SpO2 at 90 – 92%

    • Although there has been anecdotal concern for aerosolization of respiratory secretions, this claim has not been supported by recent publications. A well-seated HFNC system is not associated with increased risk of viral transmission to HCWs. Judicious use of HFNC can avert intubation. This is particularly desirable, since intubation is associated with major acute aerosol generation, higher risk of transmission, and potentially excessive utilization of ventilators.  

    • SSCI Guidelines: HFNC is now recommend as the immediate step up from NC in appropriate patients. Candidates for HFNC include:

      • Patients with isolated hypoxemic respiratory failure

      • Patients who are alert, interactive, and able to maintain a tight cannula interface and manage their pulmonary toilet (absence of encephalopathy)

      • Patients with DNI status

    • Care of patients on HFNC requires ACE PPE

    • Do not exceed flow rates of 30 L/min


  • Non-Rebreather (NRB) Mask Oxygen

    • Initiate if patient displays worsening hypoxemia on 6 L/min NC

    • Oxygen delivered at 15 L/min (maximum from wall)

    • In anticipation of possible intubation (even though RSI), patients should be made NPO when oxygen requirements are escalating


  • Invasive Mechanical Ventilation (IMV)

    • See protocol for COVID-19 ARDS: General Mechanical Ventilation


Other Respiratory Procedures

  • Pulmonary Toilet

    • Awake patients should be provided a Yankauer suction wand to clear their own expectorated secretions

    • When not being used, the Yankauer should be placed in its sleeve


  • Inhaled Bronchodilator or Corticosteroid Therapy

    • Whenever possible, bronchodilators or corticosteroids should be delivered by metered dose inhalation (MDI) using a spacer device. In mechanically ventilated patients, bronchodilators should be delivered using an in-line MDI adapter.

    • Nebulized bronchodilators should be avoided whenever possible. Select circumstances in which nebulized therapy may be required include: poor synchronization (altered mental status, respiratory distress or tachypnea) or ineffective inspiratory effort


  • Lower Respiratory Tract Suctioning – Therapeutic

    • Deep Ballard suctioning is performed when there is suspicion for sputum plugging (e.g. high peak airway pressure)


  • Lower Respiratory Tract Suctioning – Diagnostic

    • Collection of mini-BAL is an aerosol-generative procedure that creates an open circuit during attachment and removal of the Lukens trap

    • Reasons to obtain mini-BAL include:

      • Microbiologic diagnosis of VAP

      • Detection of co-infection or alternative infection diagnosis in COVID-19 PUIs

      • Collection of lower respiratory sample for COVID rRT-PCR testing

    • Indications for mini-BAL

      • Clinical Pulmonary Infection Score (CPIS) ≥ 6 (MDCalc)

      • Evaluation of cryptic pneumonia in COVID-19 PUIs, based on clinical judgement

    • All mini-BAL samples should be personally walked to the lab



  • Flexible Bronchoscopy

    • Bronchoscopy should be avoided if possible in COVID-19 patients and PUIs

    • Relative indications for bronchoscopy include:

      • Severe sputum plugging with atelectasis of ≥ 2 lobes or entire hemithorax

      • Localization of massive hemoptysis

      • Positioning of double lumen ETT

    • Bronchoscopy should be performed with a disposable fiberoptic bronchoscope

Information presented on this website does not reflect the views or positions of the US Veterans Health Administration, Emory Healthcare, or its affiliated institutions. This is a rapidly evolving field. As such. the content on this site is being updated daily and protocols will be updated in real time.  The purpose of this site is to provide a centralized resource for ICU topics and protocols to promote the well-being of hospitalized or critically ill patients suffering from COVID-19.  Defer to your institutional guidelines for all clinical practice decisions.


© 2020  Victor Tseng, MD