Approach

No specific treatments are known to be effective for COVID-19 yet; therefore, the mainstay of management is early recognition and optimized supportive care to relieve symptoms and to support organ function in more severe illness. Patients should be managed in a hospital setting where possible; however, home care may be suitable for selected patients with mild illness unless there is concern about rapid deterioration or an inability to promptly return to hospital if necessary.

Rationing of medical resources may be required during the pandemic if healthcare infrastructures are overwhelmed. This raises many ethical questions on how to best triage patients to save the most lives. Recommendations have been suggested, but there is no international guidance on this issue as yet.[166][167][168]

Infection prevention and control

Immediately isolate all suspected or confirmed cases in an area separate from other patients. Suspected cases should be given a mask and kept at least 3 feet (1 meter) from other suspected cases. Implement appropriate infection prevention and control procedures. COVID-19 is a notifiable disease; report all suspected and confirmed cases to your local health authorities. 

Detailed guidance on infection prevention and control procedures are available from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC):

The WHO recommends that patients should remain in isolation for 2 weeks after symptoms disappear, and visitors should not be allowed until the end of this period.[169] Guidance on when to stop isolation depends on local circumstances and may differ between countries; consult local guidelines.

Severe COVID-19

Promptly admit patients with pneumonia or acute respiratory distress to an appropriate healthcare facility and start supportive care depending on the clinical presentation. Patients with impending or established respiratory failure should be admitted to an intensive care unit. Approximately 14% of patients present with severe illness requiring oxygen therapy, and 5% present with critical illness requiring intensive care unit treatment.[9] The median time from onset of symptoms to hospital admission is reported to be approximately 7 days.[20][37]

Admission to critical care

  • Assess all adults for frailty on admission to hospital, irrespective of age and COVID-19 status, using the Clinical Frailty Scale (CFS). Clinical frailty scale external link opens in a new window

  • Discuss the risks, benefits, and potential outcomes of available treatment options with patients and their families using decision support tools where available. Take patient wishes and expectations into account when considering the ceiling of treatment.

  • Involve critical care teams in discussions about admission to critical care for patients where:

    • The CFS score suggests the person is less frail (e.g., CFS <5), they are likely to benefit from critical care organ support, and the patient wants critical care treatment; or

    • The CFS score suggests the person is more frail (e.g., CFS ≥5), there is uncertainty regarding the benefit of critical care organ support, and critical care advice is needed to help the decision about treatment.

  • Take into account the impact of underlying pathologies, comorbidities, and severity of acute illness.[170]

Supportive therapies

  • Oxygen and airway management: give supplemental oxygen at a rate of 5 L/minute to patients with severe acute respiratory infection and respiratory distress, hypoxemia, shock, or SpO₂ <90%.[5][171] Titrate flow rates to reach a target SpO₂ ≥94% during resuscitation.[5] Use a face mask with a reservoir bag (at 10-15 L/minute) if the patient is in critical condition. Once the patient is stable, the target SpO₂ is >90% in children and nonpregnant adults, and ≥92% to 95% in pregnant women. Nasal prongs or a nasal cannula are preferred in young children.[5] Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[171]

  • Fluids: manage fluids conservatively in adults and children with severe acute respiratory infection when there is no evidence of shock as aggressive fluid resuscitation may worsen oxygenation.[5]

  • Prevention of complications: implement standard interventions to prevent complications associated with critical illness.[5] Complications such as acute respiratory distress syndrome (ARDS), sepsis, and septic shock should be managed according to usual protocols. See our Complications section for more information. 

Antimicrobials

  • Start empiric antimicrobials to cover other potential bacterial pathogens that may cause respiratory infection, according to local protocols. Give within 1 hour of initial patient assessment for patients with suspected sepsis. Choice of empiric antimicrobials should be based on the clinical diagnosis, and local epidemiology and susceptibility data. Consider treatment with a neuraminidase inhibitor until influenza is ruled out. De-escalate empiric therapy based on microbiology results and clinical judgment.[5]

  • Some patients with severe illness may require continued antimicrobial therapy once COVID-19 has been confirmed depending on the clinical circumstances.

Antipyretic/analgesic

  • Guidelines recommend an antipyretic/analgesic for the relief of fever and pain.[5][171] However, current evidence does not support routine antipyretic administration to treat fever in acute respiratory infections.[172]

  • Some clinicians have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen could worsen COVID-19 or have a negative impact on disease outcome based on anecdotal reports.[173] There is currently no strong evidence to support this. The European Medicines Agency, the Food and Drug Administration, and the WHO do not recommend avoiding NSAIDs in COVID-19 when clinically indicated. However, NHS UK recommends acetaminophen as the drug of choice until there is more information available.[174][175][176]

  • Ibuprofen is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).

Monitoring

  • Monitor patients closely for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and immediately start general supportive care interventions as indicated (e.g., hemodialysis, vasopressor therapy, fluid resuscitation, ventilation, antimicrobials) as appropriate.[5]

Advanced oxygen/ventilatory support

  • Follow local infection prevention and control procedures to prevent transmission to healthcare workers, especially when performing aerosol-generating procedures.

  • Provide advanced oxygen/ventilatory support in patients who are deteriorating and failing to respond to standard oxygen therapy.[5] Some patients may develop severe hypoxic respiratory failure, requiring a high fraction of inspired oxygen, and high air flow rates to match inspiratory flow demand. Patients may also have increased work of breathing, demanding positive pressure breathing assistance. 

  • Consider a trial of high-flow nasal oxygen, or noninvasive ventilation if high-flow nasal oxygen is not available, in patients with hypoxemic respiratory failure.[5][171] Monitor patients closely for clinical deterioration that could result in the need for urgent intubation.[5] This procedure may avoid the need for intubation and mechanical ventilation.[177]

  • Consider intubation and mechanical ventilation in patients who are acutely deteriorating. Two-thirds of patients who required critical care in the UK had mechanical ventilation within 24 hours of admission.[178] Endotracheal intubation should be performed by an experienced provider using airborne precautions. Young children, or adults who are obese or pregnant, may desaturate quickly during intubation and therefore require preoxygenation with 100% fraction of inspired oxygen (FiO₂) for 5 minutes. Mechanically ventilated patients with acute respiratory distress syndrome should receive a lung-protective, low tidal volume/low inspiratory pressure ventilation strategy (lower targets are recommended in children). A higher positive end-expiratory pressure (PEEP) strategy is preferred over a lower PEEP strategy.[5][171]

  • Consider prone ventilation in patients with persistent severe hypoxic failure.[5][171] Pregnant women may benefit from being placed in the lateral decubitus position.[5] A small cohort study of 12 patients in Wuhan City, China, with COVID-19-related acute respiratory distress syndrome suggests that spending periods of time in the prone position may improve lung recruitability.[179]

  • A trial of an inhaled pulmonary vasodilator may be considered in adults who have severe acute respiratory distress syndrome and hypoxemia despite optimizing ventilation. Lung recruitment maneuvers are suggested, but staircase recruitment maneuvers are not recommended.[171]

  • Some patients may require extracorporeal membrane oxygenation (ECMO) according to availability and expertise.[5][171][180]

  • The risk of treatment failure is high in patients with nonacutely reversible conditions, and there is also concern about nosocomial transmission with open ventilation systems and suboptimal noninvasive face mask or nasal pillow seals. More research to define the balance of benefits and risks to patients and health workers is needed.

  • Surviving Sepsis Campaign: summary of recommendations on the management of patients with COVID-19 and ARDS external link opens in a new window

  • Surviving Sepsis Campaign: summary of recommendations on the initial management of hypoxic COVID-19 patients external link opens in a new window

Experimental therapies

  • Drug therapies (e.g., antivirals) are being used in patients with COVID-19; however, unlicensed or experimental treatments should only be administered in the context of ethically-approved clinical trials.[5] See our Emerging section for more information about these treatments.

Corticosteroids

  • Corticosteroids are being used in some patients with COVID-19; however, they have been found to be ineffective and are not recommended.[20][181]

  • The WHO (as well as other international pneumonia guidelines) does not routinely recommend systemic corticosteroids for the treatment of viral pneumonia or acute respiratory distress syndrome unless they are indicated for another reason.[5] However, Surviving Sepsis Campaign guidelines on the treatment of critically ill patients with COVID-19 suggest that adults with acute respiratory distress syndrome who are receiving mechanical ventilation should receive corticosteroids, although this recommendation is based on weak evidence.[171]

  • A randomized controlled trial investigating the use of corticosteroids in patients with COVID-19 is in progress.[182]

Mild COVID-19 with risk factors

Patients with mild illness who have risk factors for poor outcomes (i.e., age >60 years, presence of comorbidities) should also be prioritized for hospital admission.[155] These patients should be managed in the same way as severe COVID-19 (above) depending on the clinical presentation.

Mild COVID-19 without risk factors

All laboratory-confirmed cases, regardless of severity, should be managed in a healthcare facility where possible. In situations where this is not possible, patients with mild illness and no risk factors (i.e., age >60 years, presence of comorbidities) can be isolated in nontraditional facilities (e.g., repurposed hotels or stadiums) or at home. This will depend on guidance from local health authorities and available resources. Forced quarantine orders are being used in some countries.[155]

Home care can be considered when the patient can be cared for by family members and follow-up with a healthcare provider or public health personnel is possible. The decision requires careful clinical judgment and should be informed by an assessment of the patient’s home environment.[155]

Patients and household members should follow appropriate infection prevention and control measures while the patient is in home care. Detailed guidance is available from the WHO and CDC:

Recommend symptomatic therapies such as an antipyretic/analgesic (taking the precautions above into account), and advise patients to keep hydrated but not to take too much fluid as this can worsen oxygenation.

Monitor patients closely and advise them to seek medical care if symptoms worsen as mild illness can rapidly progress to lower respiratory tract disease. Two negative test results (on samples collected at least 24 hours apart) are required before the patient can be released from home isolation. If testing is not possible, the patient should remain in isolation for an additional 2 weeks after symptoms resolve.[155] Guidance on when to stop isolation depends on local circumstances and may differ between countries; consult local guidelines.

Pregnancy and breastfeeding

Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as mental health and psychosocial support. There is no evidence to suggest that pregnant women present with increased risk of severe illness or fetal compromise. Data on pregnant women with COVID-19 are limited; however, pregnant women can generally be treated with the same supportive therapies detailed above, taking into account the physiologic changes that occur with pregnancy.[5][183]

Location of care

  • Manage symptomatic pregnant women with confirmed infection in a hospital setting with appropriate maternal and fetal monitoring; women with severe illness or complications may require admission to an intensive care unit.[184]

  • Isolate and monitor asymptomatic pregnant women with confirmed infection at home, if appropriate, with ultrasound fetal surveillance every 2 weeks.[184]

Delivery

  • Choice of delivery and timing should be individualized based on gestational age, as well as maternal, fetal, and delivery conditions. Induction of labor and vaginal delivery is preferred in pregnant women with confirmed COVID-19 infection to avoid unnecessary surgical complications; however, an emergency cesarean delivery may be required if medically justified (e.g., in patients with complications such as sepsis or if there is fetal distress).[5][184]

  • Corticosteroid therapy may be considered in women who are at risk of preterm birth from 24 to 37 weeks’ gestation for fetal lung maturation.[5][184][185]

Newborns and breastfeeding

  • Babies born to mothers with suspected or confirmed infection should be tested after birth.

  • The WHO recommends that mothers and infants should remain together when possible, and breastfeeding should be encouraged while applying appropriate infection prevention and control measures (e.g., performing hand hygiene before and after contact with the baby, wearing a mask while breastfeeding).[5] However, the CDC recommends that temporary separation of the mother and baby should be considered on a case-by-case basis, at least until the mother’s transmission-based precautions are discontinued. It recommends that mothers who intend to breastfeed should be encouraged to express their breast milk using a dedicated breast pump and using appropriate infection prevention and control measures in order to maintain milk supply. Expressed milk should be fed to the newborn by a healthy caregiver.[186] Consult local guidelines for specific recommendations.

Management of comorbidities

Data on the management of comorbidities in patients with COVID-19 is limited.[187] Tailor the management of critical illness to the patient’s comorbidities (e.g., decide which chronic therapies should be continued and which therapies should be temporarily stopped, monitor for drug-drug interactions).[5]

Cardiovascular disease

  • There is insufficient clinical or scientific evidence to determine how to manage hypertension in patients with COVID-19. There have been advocates for both the use and cessation of ACE inhibitors or angiotensin-II receptor antagonists in patients with hypertension due to theoretical concerns of increased expression of ACE2 in these patients.[188] However, the American Heart Association, the American College of Cardiology, the Heart Failure Society of America, and the European Society of Cardiology Council on Hypertension recommend that patients with COVID-19 who have underlying hypertension, heart failure, or ischemic heart disease should continue taking their ACE inhibitors or angiotensin-II receptor antagonists as there is no evidence to suggest that these drugs increase the risk of developing severe COVID-19. In patients with cardiovascular disease who are diagnosed with COVID-19, individualized treatment decisions should be made according to the hemodynamic status and clinical presentation of each patient.[189][190][191][192] The European Medicines Agency agrees with these recommendations.[193]

Asthma

  • There is currently no evidence of a relationship between the use of inhaled corticosteroids and COVID-19, and these agents are still considered safe to use. However, there is some evidence that inhaled corticosteroids may increase the risk of some respiratory infections in patients with asthma, and there is uncertainty over whether higher doses increase the risk of pneumonia.[194]

Cancer

  • In patients who require systemic anticancer treatment, take into account: the level of immunosuppression associated with cancer types and individual treatments, as well as any other patient-specific factors; resource issues; and balancing the risk of not treating cancer optimally versus the risk of the patient being immunosuppressed and becoming severely ill from COVID-19.[151] Guidelines are also available for patients undergoing radiation therapy.[195]

Chronic kidney disease

  • The impact of COVID-19 on chronic kidney disease has not been reported as yet; however, there are challenges for patients with suspected or confirmed COVID-19 infection who are on dialysis. Guidelines for patients on dialysis and for dialysis units have been developed.[196][197][198][199][200]

Inflammatory bowel disease

  • There is a lack of data about COVID-19 in patients with inflammatory bowel disease; however, guidelines have been developed. Patients who are already on treatment should continue their current drug regimen if their disease is stable, and contact their healthcare provider to discuss suitable options during disease flares.[201][202][203]

  • It has been suggested that patients should be screened for SARS-CoV-2 infection before starting therapy with biologics.[204]

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