MEDICINE
Review Article
Invasive and Non-Invasive Ventilation
in Patients With COVID-19
Wolfram Windisch, Steffen Weber-Carstens, Stefan Kluge, Rolf Rossaint, Tobias Welte,
Christian Karagiannidis
Summary
Background: The reported high mortality of COVID-19 patients in intensive care has
given rise to a debate over whether patients with this disease are being intubated
too soon and might instead benefit from more non-invasive ventilation.
Methods: This review is based on articles published up to 12 June 2020 that were
retrieved by a selective literature search on the topic of invasive and non-invasive
ventilation for respiratory failure in COVID-19. Guideline recommendations and
study data on patients with respiratory failure in settings other than COVID-19 are
also considered, as are the current figures of the intensive care registry of the
German Interdisciplinary Association for Intensive Care and Emergency Medicine
(Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin).
Results: The high mortality figures among patients receiving invasive ventilation that
have been reported in studies from abroad cannot be uncritically applied to the
current situation in Germany. Study data on ventilation specifically in COVID-19
patients would be needed to do justice to the special pathophysiology of this dis-
ease, but such data are lacking. Being intubated too early is evidently associated
with risks for the patient, but being intubated too late is as well. A particularly im-
portant consideration is the potential harm associated with prolonged spontaneous
breathing, with or without non-invasive assistance, as any increase in respiratory
work can seriously worsen respiratory failure. On the other hand, it is clearly unac-
ceptable to intubate patients too early merely out of concern that the medical staff
might become infected with COVID-19 if they were ventilated non-invasively.
Conclusion: Nasal high flow, non-invasive ventilation, and invasive ventilation with
intubation should be carried out in a stepwise treatment strategy, under appropriate
intensive-care monitoring and with the observance of all relevant anti-infectious
precautions. Germany is better prepared that other countries to provide COVID-19
patients with appropriate respiratory care, in view of the high per capita density of
intensive-care beds and the availability of a nationwide, interdisciplinary intensive
care registry for the guidance and coordination of intensive care in patients who
need it.
Cite this as:
Windisch W, Weber-Carstens S, Kluge S, Rossaint R, Welte T, Karagiannidis C:
Invasive and non-invasive ventilation in patients with COVID-19.
Dtsch Arztebl Int 2020; 117: 528–33. DOI: 10.3238/arztebl.2020.0528
Department of Respiratory Medicine, Kliniken der Stadt Köln gGmbH, University of Witten/Herdecke:
Prof. Dr. med. Wolfram Windisch, Prof. Dr. med. Christian Karagiannidis
Surgical Intensive Care, Department of Anesthesiology, Charité University Medical Center, Berlin:
Prof. Dr. med. Steffen Weber-Carstens
Department of Intensive Care, University Medical Center Hamburg-Eppendorf: Prof. Dr. med. Stefan
Kluge
Department of Anesthesiology, University Medical Center Aachen, RWTH Aachen University:
Prof. Dr. med. Rolf Rossaint
Director of Patient Care at MHH, The German Center for Lung Research, University Medical School
Hanover (MHH), Hanover: Prof. Dr. med. Tobias Welte
528
I
n Germany a debate has arisen on the optimal medical
care of patients with COVID-19 who require mechan-
ical ventilation (1–3). This has led to considerable
uncertainty among physicians of various specialties and
also beyond the medical profession. As a direct reaction
to the discussion, the German Respiratory Society (DGP,
Deutsche Gesellschaft für Pneumologie und Beatmungs-
medizin) has compiled detailed recommendations on
ventilation treatment in COVID-19, focusing especially
on the use of non-invasive ventilation (NIV) (1).
However, there are still no randomized controlled
trials of ventilation treatment in COVID-19. For this
reason, the prevailing recommendations regarding
ventilation are based primarily on physicians’ experi-
ence and on studies in other categories of patients (1,
4, 5). Nevertheless, in writing this review we sought
to cast light on scientific considerations and findings
that may provide assistance, against the background
of the ongoing debate, to clinicians involved in deci-
sions regarding ventilation in the explicit context of
COVID-19 pneumonia.
NIV and invasive ventilation: competing or
complementary treatment options?
In the current discussion on “excessively early” intubation,
NIV and invasive ventilation are regarded as competing
approaches. However, this assumption by no means
reflects the scientific evidence or the reality of clinical
treatment. For acute NIV, there are a large number of
randomized controlled trials on conditions other than
COVID-19 in which NIV and invasive ventilation are not
compared with each other (4). Rather, NIV in addition to a
standard treatment (oxygen, medication) is compared with
the standard treatment alone, usually in an early phase of
illness. The crucial outcome parameters are avoidance of
intubation, length of hospital stay, and mortality. NIV is
hence no better or worse than invasive ventilation; rather,
it should always be viewed primarily as an additional
measure early in the disease process as part of a stepwise
approach, at a time when the criteria for intubation are
not yet fulfilled. NIV thus has the potential to delay or
even prevent the need for intubation, making it a fixed
component of the intensive care repertoire.
Intubation of patients with COVID-19: are findings
from other countries valid for Germany?
A study from China reported mortality of 97% among
intubated patients; the median duration of ventilation
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2020; 117: 528–33

was 4 days (6). In another analysis from China, how-
ever, only 3.2% of a total of 80 409 patients with
COVID-19 of all degrees of severity were actually in-
tubated (7). The data from an Italian intensive care
cohort of 1591 patients show that 88% were intu-
bated, while the death rate among those who com-
pleted intensive care treatment was 64% (8). Fur-
thermore, the incidence of intubation in a French
study was just under 69% (9). Data from a collective
made up of residents of England, Wales, and Northern
Ireland demonstrated mortality of 67% among 1795
invasively ventilated patients (10). Finally, recent
data from the area in and around New York City show
that 3% of invasively ventilated patients survived and
25% died (11); 72% were still undergoing inpatient
treatment, so this was only a snapshot.
The circumstances in the above-mentioned coun-
tries are in no way comparable to the situation in
Germany. Early data from Germany show a long
duration of intensive care treatment in general, with
a median of 10 days, although intensive therapy
was ongoing (12). Moreover, Germany has the
highest density of intensive care beds in the world
(13). Because the pandemic affected Germany later
than Italy, for example, this country had more time
to make preparations. Decisive in this regard was
the enhancement of intensive care capacity, e.g., by
means of internal restructuring with suspension of
elective interventions and subsequent creation of
intensive care beds in the field of surgical intensive
therapy. These measures ensured that, in contrast to
other countries, long stays in intensive care units
have been possible without, to date, any shortfall in
intensive care in Germany. Very recently published
data from the USA as well show much lower mor-
tality among invasively ventilated patients compared
to other countries (36%), which is attributed to longer
preparation times and higher numbers of intensive
care beds (14). Finally, the authors of a recent system-
atic review likewise come to the conclusion that the high
mortality figures in the early publications were most
likely due to the limited intensive care resources (15).
What role can be played by the nationwide DIVI
intensive care registry?
Another crucial factor was the extremely rapid estab-
lishment of a nationwide intensive care registry by the
German Interdisciplinary Association for Intensive
Care and Emergency Medicine (DIVI, Deutsche Inter-
disziplinäre Vereinigung für Intensiv- und Notfallmedi-
zin) (16). The DIVI registry provides daily updates of
available capacity, enabling regional and supraregional
coordination of intensive care bed allocation and facili-
tating scientific evaluation of the pertinent data.
In some other countries, overcrowding of emergen-
cy rooms and intensive care facilities has led to
scenes of chaos. It may well be that the options of
NIV or nasal high-flow (NHF) treatment were not ex-
ploited to the full, with lack of coordination meaning
that intubation was followed by restricted intensive
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2020; 117: 528–33
MEDICINE
FIGURE 1
Initial lung injury
Pulmonary
edema
Capillary Vicious circle Impairment of
leakage
g of self- – Gas exchange
inflicted – Respiratory
lung injury mechanics
Increased pleural Increased res-
pressure swings piratory drive
Self-inflicted lung injury
A central role is played by the high respiratory drive of the sponta-
neously breathing and conscious patient, with or without NIV, with
increasingly impaired gas exchange and restricted respiratory
mechanics (19). The consequent high respiratory work may then lead
to high, regionally variable, fluctuations in transpulmonary pressure. It
is crucial to realize that struggling to breathe in results in a lowering of
pleural pressure that exceeds the intravascular pressure decrease.
With an additional elevation of intrathoracic blood volume on inspira-
tion, this causes an increase in transmural pulmonary vascular pres-
sure. The result is a higher risk of pulmonary edema, especially in an
already damaged lung (capillary leakage). Completing the vicious
circle, this then leads to further impairment of breathing mechanics
with decreased compliance and restriction of gas exchange, which in
turn favors shortness of breath and thus a further increase in respi-
ratory work.
NIV, Non-invasive ventilation
care monitoring. A recent report summarized the es-
sential limitations of intensive care services in China:
shortages of beds and staff, the variable level of inten-
sive care, isolated high patient volumes, and the high
rate of infection-related absence among medical per-
sonnel (17). The daily report from the German inten-
sive care registry shows mortality of only 25 to 30%
for completed intensive care treatments (18). These are
not study data, however, so they have to be interpreted
cautiously. Nevertheless, early, not yet fully analyzed
data from Germany will show mortality of somewhat
more than 50% in ventilated, hospitalized patients.
What are the limits of NIV in patients with acute
hypoxemia?
NIV must be viewed critically against the backdrop of
the two following considerations and may possibly
have to be converted to invasive ventilation after
analgosedation/intubation:
● One crucial hypothesis is that elevated respiratory
drive with increased fluctuation of pleural pressure
may cause patient self-inflicted lung injury
(P-SILI) (19). Essentially, this involves enlarge-
ment of a pre-existing capillary leak and conse-
quently worsening of pulmonary edema (Figures 1
529
MEDICINE
FIGURE 2
VILI CARDS P-SILI
Classic ARDS
The possible causes of classic ARDS in patients with COVID-19
pneumonia
ARDS Acute respiratory distress syndrome
CARDS Special form of ARDS in the initial phase of COVID-19
VILI Ventilator-induced lung injury
P-SILI Patient self-inflicted lung injury
and 2). Recently published research shows that
measurement of esophageal pressure, as surrogate
for pleural pressure, can predict NIV failure accu-
rately at an early stage (20). The tidal changes in
esophageal pressure after 2 h of NIV were signifi-
cantly lower in patients with NIV success than in
those with NIV failure.
● The Lung Safe Study, a large epidemiological
study with data from 50 countries, showed that
NIV was associated with elevated mortality when
the Horovitz index (PaO2/FIO2) was <150 mm Hg
(21). This agrees with the conclusion reached by
earlier studies, i.e., that delayed intubation is prog-
nostically unfavorable (4).
COVID-19: a special form of ARDS?
Evidence is accumulating that the course of hypox-
emic lung injury in COVID-19 pneumonia may very
well differ in various ways from that in other entities,
including a greater degree of heterogeneity (1, 22,
23). In that it also goes along with damage to the vas-
cular epithelium, and therefore the danger of multiple
organ failure, COVID-19 pneumonia can be viewed
as a systemic disease (23).
In the initial phase, radiological imaging shows
ground-glass infiltrates subpleurally and along the fis-
sures, although the elasticity of the lung may be pre-
served. Hypoxemia, sometimes severe, may never-
theless already be present. This may be explained in
part by loss of the capacity for hypoxia-driven vaso-
constriction and by disordered regulation of perfu-
sion, which subsequently goes along with a distinct
lowering of the ventilation–perfusion ratio (low
VA/Q). This then corresponds to the hypothesized
L type (low elastance, low ventilation to perfusion
ratio, low lung weight, low recruitability) (22, 23).
Some patients go on to develop severe lung injury
with extensive consolidations seen on imaging,
whereby classic acute respiratory distress syndrome
530
(ARDS) can have various causes. There is a fall in
lung compliance as a result of edema formation with a
decrease in the number of lung segments aerated,
which is associated with a subsequent increase in
right–left shunt and aggravation of hypoxemia. This
corresponds to the hypothesized H type (high elas-
tance, high right to left shunt, high lung weight, high
recruitability) (22, 23). Relevant bacterial and fungal
superinfections may occur.
It must be noted, however, that the division into L
and H types is theoretical and cannot always be ap-
plied equally to all cases of COVID-19 pneumonia.
Furthermore, a recent autopsy study found that fulmi-
nant and also peripheral pulmonary embolisms, and
not least deep vein thromboses, are frequent occur-
rences in COVID-19 (24). Moreover, a separate
autopsy study with small case numbers demonstrated
the presence of typical histopathological patterns dif-
fering from those in influenza, in particular severe
endothelial damage, more thromboses in microangio-
pathy, and angiogenesis (25). In summary, the respi-
ratory physiology, clinical, radiological, and histo-
pathological findings provide strong evidence that
ARDS in COVID-19 is subject to disease-specific
mechanisms, on which further research is needed.
Even though the physiological criteria for ARDS may
be fulfilled in the initial phase of lung injury, diffuse
alveolar injury, documented more regularly later at
autopsy, is not automatically present at this early
stage (24, 25). In the first phase (L type), therefore,
non-invasive treatment strategies (e.g., NIV or NHF)
may be feasible. If this option is pursued, it is impor-
tant first to increase the inspiratory oxygen concen-
tration, with defined limits.
If non-invasive treatment strategies prove ineffec-
tive or are not accepted, intubation may thus become
necessary even at this early stage (L type). In this
phase the tidal volumes should be low (6 mL/kg pre-
dicted body weight) (26). In some cases moderate
positive end-expiratory pressures (PEEP) may suf-
fice because the lung injury is not yet severe (26). In
particular, excessively high PEEP in the presence of
unrestricted or only slightly restricted compliance
may have negative hemodynamic consequences,
while a benefit from recruitment cannot always be
expected (22, 23). It should be noted, however, that
no published studies have evaluated the PEEP set-
tings in the early phase of COVID-19. For this rea-
son, individualized decisions on the best form of
treatment are indispensable. If, nonetheless, the dis-
ease develops to the advanced phase (H type), this is
the last opportunity, alongside PEEP adjustment
according to the ARDS Network table, to introduce
further elements of lung protective ventilation, ac-
companied if necessary by prone positioning and/or
extracorporeal procedures (5, 26, 27). New observa-
tions in small series of cases have also shown that
especially prone positioning may be helpful even at
an earlier stage of respiratory failure in COVID-19,
to improve oxygenation and ameliorate tachypnea,
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2020; 117: 528–33
 MEDICINE

both in spontaneously breathing patients (28) and in FIGURE 3

those receiving NIV (29). However, further research
is needed.
At what point should patients with COVID-19
pneumonia be intubated?
Deciding when intubation is indicated requires careful
consideration of the classic—yet never clearly de-
fined—intubation triggers. One important parameter is
persistent tachypnea despite NIV (breathing rate
≥ 30/min). However, an increase in breathing rate
does not simply reflect greater respiratory effort.
Altered respiratory mechanics, the effect of inflam-
mation on the respiratory drive, and, not least, respi-
ratory drive–modulating medications can all have an
impact on the actual respiratory effort (30, 31).
The most reliable way of assessing the elevated res-
piratory work is to measure the esophageal pressure,
but this is often difficult in the clinical setting and is
usually reserved for research. An easier method for
clinicians is palpation of the phasically increased con-
traction of the muscles used in respiration, particularly
the sternocleidomastoid muscle (31).
Since hypoxemia does not necessarily lead to end
organ damage, it cannot serve as sole intubation
trigger (30, 31). One must recall that tissue oxygen
supply depends not only on the oxygen saturation, but
also on the hemoglobin concentration and the cardiac
output. Moreover, the reason for the patient’s short-
ness of breath is frequently not restricted oxygenation
alone; rather, limitations of respiratory mechanics
often also play a role (30, 31). Correspondingly, clini-
cal observations show that severely disordered
oxygenation in COVID-19 is not necessarily accom-
panied by severe dyspnea, especially in cases where
the compliance is not yet badly affected. The signifi-
cance of restricted oxygenation should not be under-
estimated, however, as suggested by increased rates
of cardiovascular arrest owing to COVID-19 (32).
An essential factor is whether the restricted
oxygenation arises from a depressed ventilation–per-
fusion ratio or the actual presence of an intrapulmo-
nary right–left shunt. In the case of the former, a sub-
stantial improvement in oxygenation can be expected
from increasing the the oxygen supply, so intubation
can indeed sometimes be avoided at first. The situ-
ation is different in the event of non-response to
elevation of the oxygen supply, which is most likely
to rest on an increase in right–left shunt. In this case,
the gas volume is reduced, necessitating lung pro-
tective ventilation with correspondingly adjusted
PEEP, above all prone positioning, and extracorporeal
membrane oxygenation (ECMO) if required (26).
The decision whether to intubate an individual pa-
tient should therefore be based primarily on the sum
of various parameters (26, 31, 33). At this juncture, it
is important to recall that elevated respiratory work
and severe refractory hypoxemia point to the presence
of a right–left shunt despite non-invasive treatment,
and also to remember that there may be subjective
PaO2 ≤ 55 mm Hg or ≤ 7 kPa in ambient air
RR ≥ 30/min
O2/high flow*
no
SpO2 <92 % [<88 % in COPD] Continue high flow/O2
RR ≥ 30/min
yes Re-evaluation every 1 to 2 h
Treatment attempt CPAP [10 mbar]*
NIV [PEEP 5–10 mbar + ΔP 6–10 mbar]*
(target Vt <9 mL/kg)
for 1–2 h
no
Clinical deterioration Continue CPAP/NIV
Progressive infiltrates
RR ≥ 30/min
PaO2/FiO2 <150–175
yes Re-evaluation every 1 to 2 h
Intubation if no DNI order
Possible instrument-based treatment escalation in the case of acute respiratory insufficien-
cy as a result of COVID-19, as recommended in the position paper of the German Respiratory
Society (DGP) (1).
* Wearing personal protective equipment as recommended by the Robert Koch Institute.
COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure;
DNI, do not intubate; FiO2, inspiratory oxygen fraction; kPa, kilopascal; NIV, non-invasive venti-
lation; PaO2, oxygen partial pressure; PEEP, positive end-expiratory pressure; RR, respiratory
rate; SpO2, peripheral oxygen saturation; Vt, tidal volume
(Reproduced by kind permission of Georg Thieme Verlag)
lack of acceptance of such therapeutic strategies,
particularly based on the assumption of extended
treatment periods, sometimes over 2 weeks. In this
context, Figure 3 shows an algorithm for the use of
instrument-based treatment that was formulated by
the DGP (1) and has been adopted by the professional
associations for intensive care medicine in Germany
in their revised expert consensus guideline (26).
What circumstances may speak against
intubation?
In certain circumstances the advisability of intubation
may have to be considered particularly carefully de-
spite positive physiological intubation triggers:
● The patient must be in agreement with intubation
and invasive ventilation. For patients with a DNI
(do not intubate) order, primarily non-invasive
treatment methods can be used and palliative strat-
egies can be pursued if applicable (4).

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MEDICINE
● The fear of transmission to medical personnel
should never be considered an intubation trigger
(1). For this reason, staff protection has top prior-
ity. The professional associations have published
clear recommendations on the use of NIV includ-
ing advise on hygiene requirements (1, 26).
● The problem concerning the intubation criteria for
COVID-19 is that while in conventional ARDS the
severe oxygenation disorder due to the prevailing
high intrapulmonary shunt represents the primary
intubation criterion, in COVID-19, in contrast,
there is often a good treatment response to admin-
istration of oxygen/NIV due to the low V /Q (L
A
type). In this event NHF therapy may also repre-
sent a promising treatment option, although neither
in NIV nor NHF therapy is any significant escape
of infectious aerosols likely as long as leakage is
minimized by a close-fitting interface (1, 34).
● Owing to the potential pathophysiological instabil-
ity, with the danger of rapid clinical deterioration,
all non-invasive treatments must be closely moni-
tored by intensive care personnel. Intubation must
be possible at all times (1, 4).
● Finally, intubation with invasive ventilation must
always be viewed as one component in the overall
medical treatment plan. On the one hand, it is often
the only way of ensuring that the patient receives
enough oxygen to continue living. In those of ad-
vanced age with comorbidities and other organ
dysfunctions, however, especially in the event of
prolonged ventilation as is the case in COVID-19,
problems in weaning the patient off ventilation
must be anticipated (35). Weaning failure can be
associated with worsening, sometimes dramatic, of
the prognosis and of the patient’s quality of life
(36–38). Recent research in Germany shows that
prolonged weaning is unsuccessful in 36% of
cases (around 15% of patients die and circa 21%
are transferred to out-of-hospital weaning facil-
ities), despite treatment in specialized weaning
centers (38). Although no data have yet been pub-
lished on prolonged weaning after COVID-19
pneumonia, the experience to date means that the
indications for intubation of patients with risk fac-
tors for weaning failure must be considered with
great care.
Acknowledgment
The authors are extremely grateful to Prof. Uwe Janssens for his critical
scrutiny of the manuscript.
Confict of interest statement
Prof. Windisch has received lecture honoraria from Heinen and
Löwenstein, Res Med, and Philips International. He has received financial
support for research of his own initiation from Weinmann, Vivisol, Heinen
and Löwenstein, and VitalAire/Germany.
Prof. Weber-Carstens has received financial support for research of his
own initiation from Dräger.
Prof. Kluge has received research support from the companies Ambu,
E.T.View Ltd, Fisher & Paykel, Pfizer, and Xenios. He has received lecture
honoraria from ArjoHuntleigh, Astellas, Astra, Basilea, Bard, Baxter,
Biotest, CSL Behring, Cytosorbents, Fresenius, Gilead, MSD, Orion,
Pfizer, Philips, Sedana, Sorin, Xenios, and Zoll. He has received payments
for consultation from AMOMED, Astellas, Baxter, Bayer, Fresenius, Gilead,
MSD, Pfizer, and Xenios.
532
Prof. Karagiannidis has received payments for consultation from Bayer
and Xenios. He has received reimbursement of travel and accommodation
expenses from Bayer and lecture honoraria from Bayer and Xenios.
The remaining authors declare that no conflict of interest exists.
Manuscript received on 2 May 2020, revised version accepted on
25 June 2020
Translated from the original German by David Roseveare
References
1. Pfeifer M, Ewig S, Voshaar T, et al.: Positionspapier zur praktischen
Umsetzung der apparativen Differenzialtherapie der akuten respirato-
rischen Insuffizienz bei COVID-19. Deutsche Gesellschaft für Pneu-
mologie und Beatmungsmedizin e. V. (DGP). Pneumologie 2020; 74:
337–57.
2. Soldt R: Es wird zu häufig intubiert. Frankfurter Allgemeine Zeitung
(published on 7 April 2020). www.faz.net/aktuell/gesellschaft/
gesundheit/coronavirus/beatmung-beim-coronavirus-lungenfacharzt-
im-gespraech-16714565.html?premium=0xad2896d4cdb0c5a8f3c9f8
3fef8d12fd (last accessed on 29 June 2020).
3. Voshaar T, Dellweg D, Hetzel M, published by Verband Pneumol-
ogischer Kliniken: Empfehlung zur Behandlung respiratorischer Kom-
plikationen bei akuter Virusinfektion außerhalb der Intensivstation.
www.vpneumo.de/fileadmin/pdf/VPK_Emp
fehlung_neu_21.03.2020.pdf (last accessed on 29 June 2020).
4. Westhoff M, Schönhofer B, Neumann P, et al.: S3 Leitlinien: Nicht-
invasive Beatmung als Therapie der akuten respiratorischen
Insuffizienz. Pneumologie 2015; 69: 719–56.
5. Fichtner F, Moerer O, Laudi S, Weber-Carstens S, Nothacker M,
Kaisers U: Clinical practice guideline: mechanical ventilation and
extracorporeal membrane oxygenation in acute respiratory in-
sufficiency. Dtsch Arztebl Int 2018; 115: 840–7.
6. Wang Y, Lu X, Li Y, et al.: Clinical course and outcomes of 344
intensive care patients with COVID-19. J Am J Respir Crit Care Med
2020; 201; 1430–4.
7. Meng L, Qiu H, Wan L, et al.: Intubation and ventilation amid the
COVID-19 outbreak. Wuhan’s experience. Anesthesiology 2020;
132; 1317–32.
8. Grasselli G, Zangrillo A, Zanella A, et al.: COVID-19 lombardy ICU
network. Baseline characteristics and outcomes of 1591 patients
infected with SARS-CoV-2 admitted to ICUs of the Lombardy region,
Italy. JAMA 2020; 323: 1574–81.
9. Simonnet A, Chetboun M, Poissy J, et al.: Lille intensive care
COVID-19 and obesity study group. High prevalence of obesity in
severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)
requiring invasive mechanical ventilation. Obesity 2020; 28: 1195–9.
10. ICNARC: ICNARC report on COVID-19 in critical care 17 April 2020.
www.icnarc.org (last accessed on 29 June 2020).
11. Richardson S, Hirsch JS, Narasimhan M, et al.: Presenting
characteristics, comorbidities, and outcomes among 5700 patients
hospitalized with COVID-19 in the New York City Area. JAMA 2020;
323: 2052–9.
12. Dreher M, Kersten A, Bickenbach J, et al.: The characteristics of 50
hospitalized COVID-19 patients with and without ARDS. Dtsch
Arztebl Int 2020; 117: 271–8.
13. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno
RP: The variability of critical care bed numbers in Europe. Intensive
Care Med 2012; 38: 1647–53.
14. Auld SC, Caridi-Scheible M, Blum JM, et al.: Emory COVID-19
quality and clinical research collaborative. ICU and ventilator mortality
among critically ill adults with coronavirus disease 2019. Crit Care
Med 2020; DOI:10.1097/CCM.0000000000004457.
15. Quah P, Li A, Phua J: Mortality rates of patients with COVID-19 in the
intensive care unit: a systematic review of the emerging literature.
Crit Care 2020; 24: 285.
16. DIVI: DIVI Intensivregister. www.intensivregister.de (last accessed on
29 June 2020).
17. Li L, Gong S, Yan J: Covid-19 in China: ten critical issues for
intensive care medicine. Crit Care 2020; 24: 124.
18. DIVI: tagesreport. www.divi.de/register/tagesreport (last accessed on
29 June 2020).
19. Brochard L, Slutsky A, Pesenti A: Mechanical ventilation to minimize
progression of lung injury in acute respiratory failure. Am J Respir
Crit Care Med 2017; 195: 438–42.
20. Tonelli R, Fantini R, TabbiÌ L, et al.: Inspiratory effort assessment by
esophageal manometry early predicts noninvasive ventilation out-
come in de novo respiratory failure: a pilot study. Am J Respir Crit
Care Med 2020; 10.1164/rccm.201912–2512OC.
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2020; 117: 528–33

21. Bellani G, Laffey JG, Pham T, et al.: Noninvasive ventilation of
patients with acute respiratory distress syndrome. Insights from the
LUNG SAFE Study. Am J Respir Crit Care Med 2017; 195: 67–77.
22. Gattinoni L, Chiumello D, Caironi P, et al.: COVID-19 pneumonia:
different respiratory treatments for different phenotypes? Intensive
Care Med 2020; 46: 1099–102.
23. Marini JJ, Gattinoni L: Management of COVID-19 respiratory
distress. JAMA 2020; 323: 2329–30.
24. Edler C, Schröder AS, Aepfelbacher M, et al.: Dying with SARS-
CoV-2 infection—an autopsy study of the first consecutive 80 cases
in Hamburg, Germany. Int J Legal Med 2020; 134: 1275–84.
25. Ackermann M, Verleden SE, Kuehnel M, et al.: Pulmonary vascular
endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J
Med 2020; DOI: 10.1056/NEJMoa2015432.
26. Kluge S, Janssens U, Welte T, et al.: S1-Leitlinie. Empfehlungen zur
intensivmedizinischen Therapie von Patienten mit COVID-19.
www.awmf.org/uploads/tx_szleitlinien/113–001l_S1_Intensivmedizin
ische-Therapie-von-Patienten-mit-COVID-19_2020–06.pdf (last
accessed on 19 June 2020).
27. Karagiannidis C, Bein T, Windisch W: Was hat sich seit Publikation
der S3-Leitlinie „Invasive Beatmung und Einsatz extrakorporaler
Verfahren“ getan? Pneumologie 2020; 74: 46–9.
28. Elharrar X, Trigui Y, Dols AM, et al.: Use of prone positioning in non-
intubated patients with COVID-19 and hypoxemic acute respiratory
failure. JAMA. 2020; 323: 2336–8.
29. Sartini C, Tresoldi M, Scarpellini P, et al.: Respiratory parameters in
patients with COVID-19 after using noninvasive ventilation in the prone
position outside the intensive care unit. JAMA. 2020; 323: 2338–40.
30. Tobin MJ, Gardner WN: Monitoring of the control of ventilation. In:
Tobin MJ (ed). Principles and practice of intensive care monitoring.
McGraw-Hill, Inc. New York, 1998, 415–64.
31. Tobin M: Basing respiratory management of coronavirus on physio-
logical principles. Am J Respir Crit Care Med 2020; 201: (in press).
32. Baldi E, Sechi GM, Mare C, et al.: Lombardia CARe Researchers.
Out-of-hospital cardiac arrest during the Covid-19 outbreak in Italy.
N Engl J Med 2020; 382: 1708–20.
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2020; 117: 528–33
MEDICINE
33. Laghi F, Tobin MJ: Indications for mechanical ventilation. In: Tobin MJ
rd
(ed). principles and practice of mechanical ventilation. 3 edition. New
York: McGraw-Hill Inc 2012; 129–62.
34. Hui DS, Chow BK, Lo T: Exhaled air dispersion during high-flow nasal
cannula therapy versus CPAP via different masks. Eur Respir J 2019;
53: pii: 1802339.
35. Schönhofer B, Geiseler J, Dellweg D, et al.: Prolongiertes Weaning –
S2k-Leitlinie herausgegeben von der Deutschen Gesellschaft für
Pneumologie und Beatmungsmedizin e. V. Pneumologie 2019; 73:
723–814.
36. Huttmann SE, Windisch W, Storre JH: Invasive home mechanical
ventilation: living conditions and health-related quality of life.
Respiration 2015; 89: 312–21.
37. Huttmann SE, Magnet FS, Karagiannidis C, Storre JH, Windisch W:
Quality of life and life satisfaction are severely impaired in patients
with long-term invasive ventilation following ICU treatment and
unsuccessful weaning. Ann Intensive Care 2018; 8: 38.
38. Windisch W, Dellweg D, Geiseler G, et al.: Prolonged weaning from
mechanical ventilation. Results from specialized weaning centers—a
registery-based study from the WeanNet Initiative. Dtsch Arztebl Int
2020; 117: 197–204.
Corresponding author
Prof. Dr. med. Wolfram Windisch
Lungenklinik, Kliniken der Stadt Köln gGmbH
Universität Witten/Herdecke
Ostmerheimer Str. 200, 51109 Köln, Germany
windischw@kliniken-koeln.de
Cite this as:
Windisch W, Weber-Carstens S, Kluge S, Rossaint R, Welte T,
Karagiannidis C: Invasive and non-invasive ventilation in patients
with COVID-19. Dtsch Arztebl Int 2020; 117: 528–33.
DOI: 10.3238/arztebl.2020.0528
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