COVID-19

See also prevention of COVID-19 transmission in the healthcare setting; COVID-19 (peds); and COVID-19 in pregnancy.

Background

  • The current national and international pandemic is from a virus named SARS-CoV-2 (previously 2019-nCoV), which causes a disease named COVID-19 (also known as "2019 Novel Coronavirus")
  • First detected in Wuhan, China

Specific Coronavirus Sub-Types of Clinical Importance

Template:COVID epidemiology

Clinical Features

Initial Presentation

  • Many patients are asymptomatic
  • At onset of symptoms: fever, dry cough, myalgias, fatigue, shortness of breath
    • Fever and cough start early, shortness of breath noted about 9 days into illness
    • Fever not present in all adults (less common in vulnerable populations)
    • Less common: cough with sputum, sore throat, headache, congestion, GI symptoms
Symptom[1] %
Fever 87.9
Dry cough 67.7
Fatigue 38.1
Sputum production 33.4
Shortness of breath 18.6
Myalgia or arthralgia 14.8
Sore throat 13.9
Headache 13.6
Chills 11.4
Nausea or vomiting 5.0
Nasal congestion 4.8
Diarrhea 3.7
Hemoptysis 0.9
Conjunctivitis 0.8

Risk Factors for Severe Disease

  • Older adults, underlying conditions (lung disease, heart disease, diabetes)
    • Children: milder disease
    • Pregnant patients: don’t appear to be at increased risk of infection or adverse outcomes (limited data - see COVID-19 in pregnancy)

Common Complications

  • Most common complications: pneumonia, ARDS (avg 8 days from onset, 20% of patients in China)

Differential Diagnosis

Influenza-Like Illness


Causes of Pneumonia

Bacteria


Viral


Fungal


Parasitic

Evaluation

Workup

Viral Testing Background

  • In the United States, the US Centers for Disease Control is distributing the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel to public health labs through its International Reagent Resource[2]
  • Internationally the WHO has distributed kits based on the RT-PCR platform[3]
  • BIOFIRE RESP PANEL Corona Virus assay does NOT detect this subtype

Who to Test

Your local hospital guidelines may be different, depending on test availability

CDC Guidelines (The CDC has expanded testing beyond the initial travel to china recommendations[4])
  • Test any person who has fever or respiratory illness AND had close contact with a known COVID-19 patient
  • Test any person who has fever or respiratory illness AND a history of travel to CDC-classified high risk areas or areas with recent significant community spread
  • Test any person who has severe respiratory illness AND is being admitted to the hospital
  • Test any hospitalized person who has respiratory illness AND no alternative diagnosis
  • Consider testing any person who has respiratory illness AND lives in a residential facility such as a nursing home or recently returned from a cruise

Clinical Sample Collection

Testing can be done in ambulatory setting if absolutely needed (see precautions)

  • Upper respiratory tract and lower tract specimens (if available).
    • NP swabs
    • Put both of them in the same tube and send for a single test
  • For productive cough patients: can collect sputum to send for testing. CDC does NOT recommend inducing sputum (because aerosol generating)

Diagnostic Findings

COVID one pager with links.jpg
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Labs

  • Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
    • Elevated d-dimer and severe lymphopenia are associated with increased mortality
    • RT-PCR is currently test of choice for confirming cases
      • Test kit availability is currently limited as of mid March
      • Consider influenza/viral respiratory panel to identify alternative diagnoses
        • Although co-infection is possible

X-ray

    • Portable CXR preferred in PUI to prevent spread of infection
    • May be normal in early disease
    • Typical pattern is peripheral patchy ground glass opacities (GGO)
    • More opacities correlates with worse disease
    • GGOs may coalesce and appear as infiltrates

CT

  • Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
    • CT (86%) more sensitive than CXR (59%) for detecting GGOs
    • Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
    • From the American College of Radiology (3/11/20): “Generally, the findings on chest imaging in COVID-19 are not specific, and overlap with other infections, including influenza, H1N1, SARS and MERS. Being in the midst of the current flu season with a much higher prevalence of influenza in the U.S. than COVID-19, further limits the specificity of CT.”

Management

See prevention of COVID-19 transmission in the healthcare setting for PPE recommendations

General

  • Supportive care

Mild Cases

  • Supportive care is mainstay of therapy for patients with mild viral symptoms
  • Most patients will do well enough for discharge home
  • Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home

Respiratory failure

  • NIPPV may increase the spread of viral particles via droplets making early intubation the preferred airway management strategy in patients with respiratory distress/failure
    • Using 2 viral filters attached to a "2-tube NIPPV circuit" in a negative pressure room may sufficiently prevent viral spread
  • Early intubation is the preferred means of airway managment (due to the viral spread risk)

Intubation

For aerosol precautions see Prevention of COVID-19 transmission in the healthcare setting#Intubation

  • High risk procedure for aeresolization
    • Patient ideally in negative pressure room. Limit individuals in room to essential staff only.
    • PPE for all in room: N95, gown, gloves, eye shield
    • PPE for provider intubating: Consider PAPR, double glove, double gown
    • BVM with viral filter. If not viral filter do NOT BVM
    • Use checklist if available (example: File:Harbor COVID Airway Management v3-16-20.pdf)
  • Use sufficient paralytics to prevent coughing gagging
  • Most experienced provider should perform intubation.
  • Ventilator settings for Covid-19 Patients => ARDSnet protocol (see table below)
    • Mode: Volume-Assist Control
    • Volume: 6-8ml/kg of Ideal Body Weight (based on height/sex). NOT actual Body weight.
    • Respiratory Rate: 15 breaths/min
      • Increase if pre-intubation ABG/VBG shows significant acidosis
      • Adjust based on ABG PaCO2/pH results
    • PEEP: 5 (titrate via ARDSnet)
    • FiO2: 40% after intubation and monitor O2 saturation.
      • Goal SaO2 > 88%
      • If SaO2 < 88% on FiO2 of 40%, see ARDSnet and increase PEEP first.
  • Alarming Vent? See (https://rebelem.com/rebel-cast-ep-46b-vent-management-crashing-patient-haney-mallemat/)
    • DOPES = Displaced ET tube or cuff, Obstructed ET tube: pt biting tube, kink in tube, mucous plug, Pneumothorax, Equipment: Tube from ETT to Vent, Stacked breaths: auto-PEEP (typically asthma/COPD, results from decreased ability to expire air)
    • DOTTS = Disconnect from vent (can push down on pt’s chest if concern for auto-PEEP), FOR COVID-19 SKIP Oxygenate with 100% BVM (evaluates for ETT dislodgement, bilateral breath sounds, cuff leak, crepitus, difficulty bagging), Tube check for mucous plug or kink or dislodgement, Tweak vent for autoPEEP (decreased RR, decreased inspiratory time with changing E:I ratio), Sonography for pneumothorax.
    • Peak Vs Plateau Pressure
      • Super important to keep alveolar pressure low to prevent barotrauma
      • Peak Pressure is pressure of entire system (vent, ET tube, trachea, bronchus, bronchioles, alveoli). High peak pressure does not equal barotrauma
      • Plateau pressure - check with button on vent (may say plateau pressure or end-inspiratory hold)
      • High Peak and Normal Plateau - problem with vent, ET tube, bronchoconstriction (reactive airway disease/asthma/COPD).
      • High Peak and High Plateau - Compliance issue (pneumothorax, problem with alveoli like ARDS, fluid overload). Need to decrease pressure to prevent barotrauma.
      • Plateau pressures should be kept < 30mmHg if possible.

Ardsnet.jpg http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf

Ardsnet2.png Vent basics resource: https://emcrit.org/wp-content/uploads/2010/05/Managing-Initial-Vent-ED.pdf

Investigational Agents

Generally not started in ED setting; ** CDC does not recommend for or against any investigational therapies at this time

  • Remdesivir (IV)
    • Consider for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
    • Contact Gilead directly for use: compassionateaccess@gilead.com
    • Background: novel antiviral nucleotide analog. Initially developed for Ebola and Marburg (has since been found to show activity against other single stranded RNA viruses such as RSV, Lassa fever virus, Nipah virus and the coronaviruses including MERS and SARS)
      • 3 clinical trials across country (one is NIH adaptive trial)
      • 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients
  • Limited data on Ritonavir, chloroquine, and hydroxychloroquine

Contraindicated

  • Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. MERS, SARS)
  • Avoid nebulizers as they are generally ineffective may aerosolize virus
    • Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
  • Generally avoid BiPAP and high-flow nasal oxygen as these may increase viral spread
    • WHO cautiously states that high flow oxygen may be occasionally indicated.
  • There is anecdotal concern about NSAID use; some have suggested preferentially using acetaminophen however, there are no formal recommendations to avoid NSAIDs at this time

Disposition

  • Mild cases for persons under investigation for Covid-19 awaiting a positive test result can self quarantine at home in conjunction with the local Public Health Dept
  • If admitting, needs to be placed in negative pressure isolation room with airborne and droplet precautions

Decision To Hospitalize

  • Mild symptoms may go home and self-isolate/quarantine
    • Note: symptoms may worsen over 2nd week of illness
  • Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care
  • May consider discontinuation of hospital isolation when:
    • Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing

Prognosis

All-Comer

  • Case fatality rate (CFR) = 2-4% (from Hubei data)
    • SARS ~ 10%
    • MERS ~ 35%
    • Seasonal flu ~ 0.1-0.2%
    • 1918 Pandemic Influenza ~ 2-3%

Relation to Age

Case fatality rates by country, age, and percent (%)
Age 80+ 70–79 60–69 50–59 40–49 30–39 20–29 10–19 0–9
China as of 11 February[5] 14.8 8.0 3.6 1.3 0.4 0.2 0.2 0.2 0.0
Italy as of 16 March[6] 19.2 11.8 3.2 1.0 0.3 0.2 0.0 0.0 0.0
South Korea as of 21 March[7] 10.24 6.28 1.52 0.42 0.08 0.11 0.0 0.0 0.0

See Also

COVID-19 Pages

External Links

Video

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References

  1. ↑ World Health Organization. "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)" (PDF): 11–12. Retrieved 5 March 2020.
  2. ↑ https://www.internationalreagentresource.org/
  3. ↑ Sheridan, Cormac . "Coronavirus and the race to distribute reliable diagnostics". Nature Biotechnology https://www.nature.com/articles/d41587-020-00002-2
  4. ↑ Criteria to Guide Evaluation and Laboratory Testing for COVID-19 https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
  5. ↑ The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team (17 February 2020). "The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020". China CDC Weekly. 2 (8): 113–122. Retrieved 18 March 2020.
  6. ↑ Epidemia COVID-19. Aggiornamento nazionale 16 marzo 2020" (PDF) (in Italian). Rome: Istituto Superiore di Sanità. 16 March 2020. Retrieved 18 March 2020.
  7. ↑ "코로나바이러스감염증-19 국내 발생 현황 (3월 21일, 정례브리핑)". Korea Centers for Disease Control and Prevention. 21 March 2020. Retrieved 21 March 2020.
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