A review of the role of non-invasive ventilation in critical care responses to COVID-19 in low- and middle-income countries: lessons learnt from Baghdad

In 2021, the burden of the coronavirus disease 2019 (COVID-19) pandemic became especially severe in low- and middle-income countries (LMICs). With high numbers of patients requiring advanced respiratory support and invasive mechanical ventilation (IMV), many ICUs were overwhelmed. This problem is particularly pronounced in LMICs, where the availability of intensive care beds may be limited. Non-invasive ventilation (NIV) has been increasingly used in COVID-19, as both a bridge to intubation as well as a definitive treatment. Use of NIV may be a feasible management strategy in settings where performing IMV is not possible on a large scale due to resource constraints. During 2020–2021, Médecins Sans Frontière helped manage a COVID-19 ICU in Baghdad, Iraq. The predominant mode of treatment was NIV. Due to a shortage of intensive care ventilators, NIV was delivered in the majority of cases by home continuous positive airway pressure machines. In total, 709 patients were admitted to the ICU during the study period with an overall mortality of 61.1%. In addition to the ventilation strategy, patients must be treated holistically, with a comprehensive package of critical care. We aim to highlight the role of NIV in this setting and summarise our experiences to assist future critical care projects during the pandemic.