The Italian Coronavirus disease 2019 outbreak: Recommendations from clinical practice

Italy has the highest number of cases (41,035) and deaths (3405) due to COVID‐19 in Europe and is second globally as of 20 March 2020. Doctors there faced many challenges with the onset of the COVID‐19 outbreak throughout Italy and it is likely that other countries will face similar challenges in the coming weeks and months. Here are the details of challenges faced: Clinical management Specific aspects of COVID‐19 patient care distinguish it from routine clinical practice In these settings, there are factors that must be considered for: oxygen administration and non‐invasive ventilation of the spontaneously ventilating patient; airway management of the patient requiring tracheal intubation; clinical management with PPE; and human factors. Oxygen administration Given the aggressive pulmonary involvement associated with COVID‐19, the requirement for non‐invasive or invasive oxygen therapy is likely. All oxygen administration strategies in the spontaneously ventilating patient carry risks of aerosolisation and disease transmission. Hudson and Venturi masks, nasal cannulae and helmets, carry a lower‐risk of transmission when compared with high‐flow nasal oxygen and non‐invasive ventilation with facemasks or hoods. Airway management Protocols and experiences in airway management for this and other coronavirus outbreaks, as confirmed by our ongoing experience in Italy, is a necessity to rigorously prepare for airway management. This includes utilisation of cognitive aids such as checklists, cross‐checking and pre‐planned and explicitly defined airway management strategies 36. Any airway management procedure should be managed electively rather than as an emergency, and any means to maximise first‐pass success should be adopted. Procedures should be performed in a negative pressure chamber (if available) or isolation area that is equipped with a replenished, complete and checked emergency airway trolley. Non‐technical skills The management of patients with COVID‐19 places additional physical and psychological burdens on healthcare workers. Physical burdens include repeated donning and doffing of PPE and physical restrictions to routine practice due to PPE. Psychological burdens include: management in unfamiliar environments; communication challenges with PPE; and changes to standard practice. To read complete report-



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