Pan American Health Organization · Version 1, 2020
Rapid GRADE-adapted recommendations for intensive care management of critically ill adults with COVID-19.
- Issuer
- Pan American Health Organization
- Edition
- Version 1, 2020
- Audience
- Physicians in emergency medicine, pulmonology, intensive care medicine, internal medicine, anaesthesiology, infectious disease; inhalation therapists, nurses, pharmaceutical chemists; decision-makers and government entities
- Evidence
- GRADE-rated recommendations based on rapid adaptation of WHO and Surviving Sepsis Campaign guidelines
- Reviewed
- 20 Oct 2026 · GMJ
What this guideline says
GMJ summary
This rapid guideline adaptation provides evidence-informed recommendations for managing critically ill adult patients with COVID-19 in intensive care units across the Americas. Developed by PAHO using GRADE methodology, it addresses infection control, specimen collection, respiratory support, hemodynamic management, pharmacological interventions, and prevention of complications.
Key recommendations include use of N-95 respirators for aerosol-generating procedures, low tidal volume ventilation (4–8 mL/kg predicted body weight with plateau pressures below 30 cm H₂O) for ARDS, conservative fluid strategies, prone positioning for 12–16 hours in moderate to severe ARDS, and norepinephrine as first-line vasopressor targeting mean arterial pressure of 60–65 mmHg. The guideline recommends against routine corticosteroids in respiratory failure without ARDS and notes insufficient evidence for antivirals, chloroquine, hydroxychloroquine, convalescent plasma, and tocilizumab.
This is designated a ‘living guideline’ with continuous updates as new evidence emerges from ongoing clinical trials, particularly regarding pharmacological interventions.
Key points
For clinicians — doses and thresholds as stated in the guideline
- For mechanically ventilated adults with COVID-19 and ARDS: use low tidal volume ventilation (4–8 mL/kg predicted body weight) and maintain plateau pressures below 30 cm H₂O (strong recommendation, moderate evidence)
- Maintain SpO₂ at ≥94% initially in patients with ARDS, respiratory failure, hypoxemia or shock; once stabilised on oxygen, maintain SpO₂ no higher than 96% (strong recommendations, moderate evidence)
- For moderate to severe ARDS: prone ventilation for 12–16 hours is suggested versus non-prone ventilation (conditional recommendation, low evidence)
- Conservative fluid strategy recommended over liberal strategy for mechanically ventilated adults with COVID-19 and ARDS (strong recommendation, low evidence)
- Norepinephrine as first-line vasopressor; titrate to achieve mean arterial pressure of 60–65 mmHg (conditional recommendations, low-moderate evidence)
- For acute resuscitation in shock: administer 250–500 mL crystalloid solution (normal saline or Ringer's lactate) rather than colloid; avoid hydroxyethyl starches, gelatins, or dextrans (strong recommendations, low evidence)
- N-95 respirator masks (or FFP2 equivalent) required for healthcare workers performing aerosol-generating procedures in ICU, including intubation, bronchoscopy, open suctioning, nebulised treatment, and proning
- Empiric antimicrobials for 5–7 days in mechanically ventilated patients with respiratory failure; de-escalate based on microbiology results (conditional recommendation, low evidence)
GRADE evidence quality and strength of recommendation definitions
Table extracted from the guideline
| Grade/Strength | Meaning |
|---|---|
| High quality | Further research is very unlikely to change our confidence in the estimate of effect |
| Moderate quality | Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate |
| Low quality | Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate |
| Very low quality | Any estimated of effect is very uncertain |
| Strong recommendation | Should be used. New evidence is unlikely to change the recommendation |
| Conditional recommendation | Could be used. New evidence may change the recommendation |
Source: Pan American Health Organization, Guidelines for Critical Care of Seriously Ill Adult Patients with Coronavirus (COVID-19) in the Americas (Short Version). Reproduced in summary form.
From the guideline
Verbatim
“In mechanically ventilated adults with COVID 19 and ARDS, it is recommended to use low tidal volume ventilation (4–8 mL/kg of predicted body weight) and to maintain plateau pressures below 30 cm H₂O.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
This PAHO guideline arrived at a critical moment in 2020 when Georgian ICUs faced unprecedented demand and evidence was rapidly evolving. The emphasis on GRADE methodology and transparent acknowledgment of evidence quality—much of it low or very low—provided clinicians with honest guidance during profound uncertainty. For Georgian colleagues, I would stress three immediately actionable recommendations: the ventilator settings (4–8 mL/kg tidal volume, plateau pressure below 30 cm H₂O), the oxygen saturation targets (94–96%), and the conservative fluid strategy, all strongly supported by moderate evidence from pre-COVID ARDS research. The pragmatic adaptations—permitting peripheral vasopressor administration when central lines are unavailable, specifying natural ventilation requirements when negative pressure rooms are scarce—reflect realities in our regional healthcare infrastructure. The realistic caveat is prone positioning: while evidence-supported for moderate-to-severe ARDS, it requires adequate staffing ratios and training that may not exist in all Georgian ICUs, particularly during surge conditions when the intervention is most needed.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 20 Oct 2026
Applicability
Georgia and the South Caucasus
This guideline addresses critical resource and infrastructure considerations highly relevant to Georgia and the South Caucasus. The recommendations on natural ventilation (minimum 160 L/s/patient for airborne precaution rooms, with alternatives when mechanical systems are unavailable) and peripheral administration of vasopressors when central venous catheters are not immediately available reflect pragmatic adaptations for resource-constrained settings. Georgian ICUs implementing these protocols would need to assess local capacity for prone positioning (requiring sufficient trained personnel), ECMO availability and referral pathways, and institutional protocols for biosafety in specimen collection. The emphasis on conservative fluid strategies, use of crystalloids over colloids, and antimicrobial stewardship with de-escalation aligns with rational resource utilisation. National programmes should validate laboratory procedures for endotracheal aspirates to avoid false negatives and establish institutional triage protocols for ICU admission, particularly important given potential surge capacity challenges in regional healthcare systems.
Questions this guideline answers
Quick answers
What oxygen saturation targets should be used for COVID-19 patients?
Give supplementary oxygen immediately to patients with ARDS, respiratory failure, hypoxemia or shock until SpO₂ is ≥94% (strong recommendation). Once receiving oxygen, maintain SpO₂ at no higher than 96% (strong recommendation, moderate evidence).
What are the ventilator settings for COVID-19 patients with ARDS?
Use low tidal volume ventilation (4–8 mL/kg predicted body weight) and maintain plateau pressures below 30 cm H₂O (strong recommendation, moderate evidence). Apply a conservative PEEP strategy to prevent barotrauma. For moderate to severe ARDS, prone ventilation for 12–16 hours is suggested (conditional recommendation).
Should corticosteroids be used in COVID-19 patients?
In mechanically ventilated adults with respiratory failure without ARDS, corticosteroids are suggested against (conditional recommendation, low evidence). For patients with ARDS, there is insufficient evidence to make a recommendation. Low-dose corticosteroid therapy is suggested for patients in shock requiring a second vasopressor (conditional recommendation).
What fluid resuscitation strategy should be used for COVID-19 patients in shock?
Use a conservative fluid strategy rather than liberal. Administer 250–500 mL of crystalloid solution (normal saline or Ringer's lactate) rather than colloid (strong recommendation). Use buffered/balanced crystalloids if available. Do not use hydroxyethyl starches, gelatins, or dextrans (strong recommendation).
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Quality & accreditation
Other guidelines on this topic
- Managing People with Asthma during COVID-19: Considerations for Health Providers
- Technical recommendations for the configuration of a specialized Emergency Medical Team for the treatment of Severe Acute Respiratory Infection (SARI). Version 3.5
- Technical and Regulatory Aspects of the Use of Pulse Oximeters in Monitoring COVID-19 Patients
- Assessment of infection prevention and control practices for COVID-19 isolation areas in healthcare facilities
- Initial care of persons with acute respiratory illness (ARI) in the context of coronavirus disease (COVID-19) in healthcare facilities: assess the risk, isolate, refer
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Version 1, 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish, Portuguese
- Scope
- Infection control, specimen collection, respiratory support, hemodynamic management, pharmacological treatment, and prevention of complications in critically ill adult COVID-19 patients
- Audience
- Physicians in emergency medicine, pulmonology, intensive care medicine, internal medicine, anaesthesiology, infectious disease; inhalation therapists, nurses, pharmaceutical chemists; decision-makers and government entities
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated recommendations based on rapid adaptation of WHO and Surviving Sepsis Campaign guidelines
- Next review
- Living guideline with continuous updates
- Record history
- Created 20 Oct 2026 · updated 20 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guideline for Critical Care of Seriously Ill Adult Patients with Coronavirus (COVID-19) in the Americas. Short Version – V1. Washington, D.C.: PAHO; 2020. (PAHO/PHE/EIH/COVID-19/20-0001)GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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