Clinical Guidelines


For adults with COVID-19

In adults with COVID-19, we suggest starting supplemental oxygen if the peripheral oxygen saturation (SPO2) is < 92%, and recommend starting supplemental oxygen if SPO2 is < 90% 

Acute hypoxemic respiratory failure

  1. For adults with COVID-19 and acute hypoxemic respiratory failure on oxygen, we recommend that SPO2 be maintained no higher than 96%. 
  2. For adults with COVID-19 and acute hypoxemic respiratory failure despite conventional oxygen therapy, we suggest using HFNC over conventional oxygen therapy. 

  3. We suggest using HFNC over NIPPV. 

  4. If HFNC is not available and there is no urgent indication for endotracheal intubation, we suggest a trial of NIPPV with close monitoring and short-interval assessment for worsening of respiratory failure.

  5. We were not able to make a recommendation regarding the use of helmet NIPPV compared with mask NIPPV. It is an option, but we are not certain about its safety or efficacy in COVID-19. 

  6. In adults with COVID-19 receiving NIPPV or HFNC, we recommend close monitoring for worsening of respiratory status, and early intubation in a controlled setting if worsening occurs. 


In mechanically ventilated adults with COVID-19 and ARDS

  1. We recommend using low tidal volume (Vt) ventilation (Vt 4-8 mL/kg of predicted body weight), over higher tidal volumes (Vt>8 mL/kg). 

  2. We recommend targeting plateau pressures (Pplat) of < 30 cm H2O. 

  3. We suggest using a conservative fluid strategy over a liberal fluid strategy.

  4. We recommend against the routine use of inhaled nitric oxide.

Moderate to severe ARDS

In mechanically ventilated adults with COVID-19 and moderate to severe ARDS:

  1. We suggest using a higher PEEP strategy, over a lower PEEP strategy.

    Remarks: If using a higher PEEP strategy (i.e., PEEP > 10 cm H2O), clinicians should monitor patients for barotrauma. 

  2. We suggest prone ventilation for 12 to 16 hours, over no prone ventilation. 
  3. We suggest using, as needed, intermittent boluses of neuromuscular blocking agents (NMBA), over continuous NMBA infusion, to facilitate protective lung ventilation. 
  4. In the event of persistent ventilator dyssynchrony, the need for ongoing deep sedation, prone ventilation, or persistently high plateau pressures, we suggest using a continuous NMBA infusion for up to 48 hours. 


  1. In mechanically ventilated adults with COVID-19, severe ARDS and hypoxemia despite optimizing ventilation and other rescue strategies, we suggest a trial of inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off. 

  2. For mechanically ventilated adults with COVID-19 and hypoxemia despite optimizing ventilation, we suggest using recruitment maneuvers, over not using recruitment maneuvers. 

  3. If recruitment maneuvers are used, we recommend against using staircase (incremental PEEP) recruitment maneuvers. 

  4. In mechanically ventilated adults with COVID-19 and refractory hypoxemia despite optimizing ventilation, use of rescue therapies, and proning, we suggest using venovenous (VV) ECMO if available, or referring the patient to an ECMO center.

    Remark: Due to the resource-intensive nature of ECMO, and the need for experienced centers and healthcare workers, and infrastructure, ECMO should only be considered in carefully selected patients with COVID-19 and severe ARDS. 

From: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

The CCEPP team has worked to have the content of this site informally peer-reviewed. However, it does not constitute official advice or guidance unless otherwise indicated. Please use your own discretion and judgement when applying information from this site to your practice.