COVID-19: Difference between revisions
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==Management==
==Management==
''See [[prevention of COVID-19 transmission in the healthcare setting]] for PPE recommendations''
''See [[prevention of COVID-19 transmission in the healthcare setting]] for PPE recommendations''
===General===
*Supportive care
===Mild Cases===
===Mild Cases===
*Supportive care is mainstay of therapy for patients with mild viral symptoms
*Supportive care is mainstay of therapy for patients with mild viral symptoms

Revision as of 22:01, 21 March 2020

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)
  • According to limited ICU data (21 cases) from Washington state (Arentz et al):
    • Vasodilatory shock reported in 67% of ICU admissions
    • Cardiomyopathy reported in 33% of ICU admissions
    • Mortality reported 67% of ICU admissions

Differential Diagnosis

Influenza-Like Illness

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation

Workup

Viral Testing Background (Real-Time RT-PCR)

  • Internationally the WHO has distributed kits[2]
  • In the United States, the US Centers for Disease Control (CDC) is distributing testing to public health labs[3]
  • BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype

Who to Test (Persons Under Investigation)

  • Patients should be carefully evaluated to determine if they meet Persons Under Investigation (PUI) criteria
  • Due to a lack of available tests, non-PUI patients (including the worried well) should not have testing performed
  • Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g. influenza, RSV)
    • In many systems, testing algorithms assume patients do not have COVID-19 if influenza or RSV positive
CDC PUI Guidance[4]

Your local PUI testing guidelines may be different, depending on test availability and local epidemiology; see state or local health departments and internal hospital resources

  • "Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested."
  • Priorities for testing include:
    1. Hospitalized patients who have signs and symptoms compatible with COVID-19^ (in order to inform decisions related to infection control)
    2. Other symptomatic individuals with risk factors for severe disease
      • Older adults
      • Individuals with chronic medical conditions and/or an immunocompromised state (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease)
    3. Symptomatic persons who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient
      • Including healthcare personnel
      • INcluding history of travel from affected geographic areas

^Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).

Clinical Sample Collection[5]

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

  1. Upper respiratory tract specimen
    • Nasopharyngeal (NP) swab
      • Some systems allow sending both flu/RSV and COVID-19 test on the same swab to conserve testing supplies
  2. Additionally include lower tract specimen, if available
    • CDC does NOT recommend inducing sputum (because aerosol generating)
    • For productive cough patients: collect sputum
    • For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation): collect lower respiratory tract aspirate or bronchoalveolar lavage sample
    • May include in same testing tube as upper respiratory track specimen (i.e. send as a single test) in some systems

Diagnostic Findings

COVID one pager with links.jpg
COVID one pager with links 2.jpg
Covidcxr.jpg

Labs

  • Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
  • 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 viral respiratory panel to identify alternative diagnoses though co-infection has been reported as high as 7-20%

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.”

US

  • Uncertain role in diagnosis at this time
    • May reveal B lines, consolidation, or "ragged" appearance of pleural line

Management

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

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 of Potential COVID-19 Patients

Aerosol-generating procedure: see this link for PPE recommendations and related precautions

  • Use checklist if available (see example: File:Harbor COVID Airway Management v3-16-20.pdf)
  • Use BVM with viral filter or avoid BVM altogether, if possible
  • Use RSI to prevent coughing gagging; consider higher dosing of paralytics.
  • Use video laryngoscopy to keep provider face further away from patient (afterwards, clean with grey wipes, observe 3 min wet time)

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 Deterioration after intubation

Lung Protective Mechanical Ventilation

Lung Protective Ventilator Settings[6] should be the default for all intubated patients, unless contraindicated. It has demonstrated mortality benefit for ARDS-like pulmonary conditions; limits barotrauma and decreases complications of high FiO2[7][8]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[9]
      • Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
    • Titrate down if plateau pressure >30 mmHg
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. Respiratory Rate (titrate for ventilation)
    • Average patient on ventilator requires 120mL/kg/min for eucapnia
    • Start 16-18 breaths/min
    • Maintain pH = 7.30-7.45
  5. FiO2/PEEP (titrate for oxygenation)
    • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80mmHg

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 and may aerosolize virus
    • Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
      • MDI equivalents: Albuterol or ipratropium
        • <20 kg or 5yrs old: 4-5 puffs with a spacer every 20 minutes. 4 breaths between puffs.
        • >20 kg or 5yrs old: 8-10 puffs with a spacer every 20 minutes. 4 breaths between puffs.
  • 4 breaths between puffs
  • 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[10] 14.8 8.0 3.6 1.3 0.4 0.2 0.2 0.2 0.0
Italy as of 16 March[11] 19.2 11.8 3.2 1.0 0.3 0.2 0.0 0.0 0.0
South Korea as of 21 March[12] 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

{{#widget:YouTube|id=exV5hEG62CY}}

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. ↑ Sheridan, Cormac . "Coronavirus and the race to distribute reliable diagnostics". Nature Biotechnology https://www.nature.com/articles/d41587-020-00002-2
  3. ↑ https://www.internationalreagentresource.org/
  4. ↑ Criteria to Guide Evaluation and Laboratory Testing for COVID-19. Updated March 20, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
  5. ↑ Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19). March 19, 2020 Revision. https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html
  6. ↑ The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  7. ↑ ARDSnet
  8. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  9. ↑ Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.
  10. ↑ 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.
  11. ↑ Epidemia COVID-19. Aggiornamento nazionale 16 marzo 2020" (PDF) (in Italian). Rome: Istituto Superiore di Sanità. 16 March 2020. Retrieved 18 March 2020.
  12. ↑ "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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