RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic

Mark Griffiths; Susanna Meade; Charlotte Summers; Daniel Francis McAuley; Alastair Proudfoot; Marta Montero Baladia; Paul M Dark; Kate Diomede; Simon J Finney; Lui G Forni; Chris Meadows; Ian A Naldrett; Brijesh Patel; Gavin D Perkins; Mark A Samaan; Laurence Sharifi; Ganesh Suntharalingam; Nicholas T Tarmey; Harriet F Young; Matt P Wise; Peter M Irving

doi:10.1136/thoraxjnl-2021-216904

RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic

Thorax. 2022 Feb;77(2):129-135. doi: 10.1136/thoraxjnl-2021-216904. Epub 2021 May 27.

Authors

Mark Griffiths^#^{1

2

3}, Susanna Meade^#⁴, Charlotte Summers^#⁵, Daniel Francis McAuley^#^{6

7}, Alastair Proudfoot^#², Marta Montero Baladia⁸, Paul M Dark⁹, Kate Diomede¹⁰, Simon J Finney¹¹, Lui G Forni^{12

13}, Chris Meadows¹⁴, Ian A Naldrett^{15

16}, Brijesh Patel^{17

18}, Gavin D Perkins¹⁹, Mark A Samaan⁴, Laurence Sharifi⁸, Ganesh Suntharalingam²⁰, Nicholas T Tarmey²¹, Harriet F Young², Matt P Wise²², Peter M Irving^{4

23}

Affiliations

¹ NHLI, Imperial College London, London, UK m.griffiths@imperial.ac.uk.
² Barts Heart Centre, St Bartholomews Hospital, London, UK.
³ William Harvey Research Institute, Queen Mary University of London, London, UK.
⁴ Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁵ Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK.
⁶ Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK.
⁷ Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
⁸ The Royal London Hospital, London, UK.
⁹ Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
¹⁰ East Kent Hospitals NHS Foundation Trust, London, UK.
¹¹ Perioperative Medicine, Barts Health NHS Trust, London, UK.
¹² Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.
¹³ University of Surrey Faculty of Health and Medical Sciences, Guildford, Surrey, UK.
¹⁴ Department of Critical Care, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK.
¹⁵ University of West London, Ealing, UK.
¹⁶ Royal Brompton & Harefield NHS Foundation Trust, London, UK.
¹⁷ AICU, Royal Brompton & Harefield NHS Foundation Trust, London, UK.
¹⁸ Anaesthetics, Imperial College London, London, UK.
¹⁹ Clinical Trials Unit, University of Warwick, Coventry, UK.
²⁰ London North West University Hospitals, London, UK.
²¹ Academic Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
²² Adult Critical Care, University Hopsital of Wales, Cardiff, UK.
²³ School of Immunology and Microbial Sciences, King's College London, London, UK.

^# Contributed equally.

PMID: 34045363
DOI: 10.1136/thoraxjnl-2021-216904

Abstract

Background: COVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from 'classical' ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template.

Methods: An 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1-9 (where 1-3 is inappropriate, 4-6 is uncertain and 7-9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again.

Results: Disagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease.

Conclusion: The expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.

Keywords: ARDS; COVID-19; assisted ventilation; critical care; non invasive ventilation; viral infection.

MeSH terms

COVID-19 Testing
COVID-19*
Humans
Pandemics
Research
Respiration, Artificial
Respiratory Distress Syndrome* / diagnosis
Respiratory Distress Syndrome* / epidemiology
Respiratory Distress Syndrome* / therapy
SARS-CoV-2
United Kingdom / epidemiology