Key recommendations
Consider whether the patient can be managed at home. Generally, patients with asymptomatic or mild disease can be managed at home or in a community facility.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Admit patients with moderate or severe disease to an appropriate healthcare facility. Assess adults for frailty on admission. Patients with critical disease require intensive care; involve the critical care team in discussions about admission to critical care when necessary. Monitor patients closely for signs of disease progression.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
Provide symptom relief as necessary. This may include treatments for fever, cough, breathlessness, anxiety, delirium, or agitation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Start supportive care according to the clinical presentation. This might include oxygen therapy, intravenous fluids, venous thromboembolism prophylaxis, high-flow nasal oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation. Sepsis and septic shock should be managed according to local protocols.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Consider empiric antibiotics if there is clinical suspicion of bacterial infection. Antibiotics may be required in patients with moderate, severe, or critical disease. Give within 1 hour of initial assessment for patients with suspected sepsis or if the patient meets high-risk criteria. Base the regimen on the clinical diagnosis, local epidemiology and susceptibility data, and local treatment guidelines.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[528]National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng173
Consider systemic corticosteroid therapy for 7 to 10 days in adults with severe or critical disease. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical disease, and probably reduce the need for invasive ventilation.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
[575]World Health Organization. Therapeutics and COVID-19: living guideline. 2020 [internet publication].
https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline
Assess whether the patient requires any rehabilitation or follow-up after discharge. Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
For full details and guidance see information below.
Location of care
The decision about location of care depends on various factors including clinical presentation, disease severity, need for supportive care, presence of risk factors for severe disease, and conditions at home (including the presence of vulnerable people). Make the decision on a case-by-case basis using the following general principles.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Mild disease: manage in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, including asymptomatic patients.
Moderate disease: manage in a healthcare facility, in a community facility, or at home. Home isolation can be considered in low-risk patients (i.e., patients who are not at high risk of deterioration).
Severe disease: manage in an appropriate healthcare facility.
Critical disease: manage in an intensive/critical care unit.
The location of care will also depend on guidance from local health authorities and available resources. Forced quarantine orders are being used in some countries.
The strongest risk factors for hospital admission are older age (odds ratio of >2 for all age groups older than 44 years, and odds ratio of 37.9 for people ages 75 years and over), heart failure, male sex, chronic kidney disease, and increased body mass index (BMI).[576]Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020 May 22;369:m1966.
https://www.bmj.com/content/369/bmj.m1966
http://www.ncbi.nlm.nih.gov/pubmed/32444366?tool=bestpractice.com
The median time from onset of symptoms to hospital admission is around 7 days.[48]Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/31986264?tool=bestpractice.com
[485]Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
https://jamanetwork.com/journals/jama/fullarticle/2761044
http://www.ncbi.nlm.nih.gov/pubmed/32031570?tool=bestpractice.com
Children are less likely to require hospitalization, but, if admitted, generally only require supportive care.[20]Castagnoli R, Votto M, Licari A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review. JAMA Pediatr. 2020 Sep 1;174(9):882-9.
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2765169
http://www.ncbi.nlm.nih.gov/pubmed/32320004?tool=bestpractice.com
[577]CDC COVID-19 Response Team. Coronavirus disease 2019 in children: United States, February 12 - April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69(14):422-6.
https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm?s_cid=mm6914e4_w
http://www.ncbi.nlm.nih.gov/pubmed/32271728?tool=bestpractice.com
Risk factors for intensive care admission in children include age <1 month, male sex, preexisting medical conditions, and presence of lower respiratory tract infection signs or symptoms at presentation.[578]Götzinger F, Santiago-García B, Noguera-Julián A, et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health. 2020 Jun 25 [Epub ahead of print].
https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30177-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32593339?tool=bestpractice.com
The majority of children who require ventilation have underlying comorbidities, most commonly cardiac disease.[409]Williams N, Radia T, Harman K, et al. COVID-19 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review of critically unwell children and the association with underlying comorbidities. Eur J Pediatr. 2020 Sep 10 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00431-020-03801-6
http://www.ncbi.nlm.nih.gov/pubmed/32914200?tool=bestpractice.com
Children with COVID-19 are reported to have similar hospitalization rates, intensive care admission rates, and mechanical ventilator use compared with those with seasonal influenza.[545]Song X, Delaney M, Shah RK, et al. Comparison of clinical features of COVID-19 vs seasonal influenza A and B in US children. JAMA Netw Open. 2020 Sep 1;3(9):e2020495.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770250
http://www.ncbi.nlm.nih.gov/pubmed/32897374?tool=bestpractice.com
Overall, 19% of hospitalized patients require noninvasive ventilation, 17% require intensive care, 9% require invasive ventilation, and 2% require extracorporeal membrane oxygenation.[486]Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020 Jun 23;15(6):e0234765.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234765
http://www.ncbi.nlm.nih.gov/pubmed/32574165?tool=bestpractice.com
The rate of intensive care admission varies between studies; however, a meta-analysis of nearly 25,000 patients found that the admission rate was 32%, and the pooled prevalence of mortality in patients in the intensive care unit was 39%.[579]Abate SM, Ahmed Ali S, Mantfardo B, et al. Rate of intensive care unit admission and outcomes among patients with coronavirus: a systematic review and meta-analysis. PLoS One. 2020 Jul 10;15(7):e0235653.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235653
http://www.ncbi.nlm.nih.gov/pubmed/32649661?tool=bestpractice.com
The most common reasons for intensive care unit admission are hypoxemic respiratory failure leading to mechanical ventilation and hypotension.[580]Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically ill patients in the Seattle region: case series. N Engl J Med. 2020 Mar 30 [Epub ahead of print].
https://www.nejm.org/doi/full/10.1056/NEJMoa2004500
http://www.ncbi.nlm.nih.gov/pubmed/32227758?tool=bestpractice.com
Patients admitted to intensive care units were older, were predominantly male, and had a median length of stay of 23 days (range 12 to 32 days).[581]Argenziano MG, Bruce SL, Slater CL, et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. BMJ. 2020 May 29;369:m1996.
https://www.bmj.com/content/369/bmj.m1996
http://www.ncbi.nlm.nih.gov/pubmed/32471884?tool=bestpractice.com
The strongest risk factors for critical illness are oxygen saturation <88%; elevated serum troponin, C-reactive protein, and D-dimer; and, to a lesser extent, older age, BMI >40, heart failure, and male sex.[576]Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020 May 22;369:m1966.
https://www.bmj.com/content/369/bmj.m1966
http://www.ncbi.nlm.nih.gov/pubmed/32444366?tool=bestpractice.com
Management of mild COVID-19
Patients with suspected or confirmed mild disease (i.e., symptomatic patients meeting the case definition for COVID-19 without evidence of hypoxia or pneumonia) and asymptomatic patients should be isolated to contain virus transmission.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Location of care
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, with telemedicine or remote visits as appropriate.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
This decision requires careful clinical judgment and should be informed by an assessment of the patient’s home environment to ensure that: infection prevention and control measures and other requirements can be met (e.g., basic hygiene, adequate ventilation); the caregiver is able to provide care and recognize when the patient may be deteriorating; the caregiver has adequate support (e.g., food, supplies, psychological support); the support of a trained health worker is available in the community.[552]World Health Organization. Home care for patients with suspected or confirmed COVID-19 and management of their contacts: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts
Isolation period
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway: 10 days after positive test (asymptomatic patients); 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms (symptomatic patients).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The Centers for Disease Control and Prevention (CDC) recommends discontinuing home isolation once at least 10 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing home isolation once at least 10 days have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used.[582]Centers for Disease Control and Prevention. Discontinuation of isolation for persons with COVID-19 not in healthcare settings. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html
If the patient is hospitalized, the CDC guidance for discontinuing isolation is the same as for moderate disease (see below).
Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the self-isolation period is 10 days in patients with milder disease who are managed in the community.[583]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication].
https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Infection prevention and control
Symptom management
Fever and pain: acetaminophen or ibuprofen are recommended.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
There is no evidence at present of severe adverse events in COVID-19 patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilization, long-term survival, or quality of life in patients with COVID-19.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
[584]European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 [internet publication].
https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19
[585]US Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020 [internet publication].
https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19
[586]Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ. 2020 Mar 27;368:m1185.
https://www.bmj.com/content/368/bmj.m1185
http://www.ncbi.nlm.nih.gov/pubmed/32220865?tool=bestpractice.com
[587]Medicines and Healthcare products Regulatory Agency; Commission on Human Medicines. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). 2020 [internet publication].
https://www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19
[588]World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19: scientific brief. 2020 [internet publication].
https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19
[589]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. 2020 [internet publication].
https://www.nice.org.uk/advice/es23/chapter/Key-messages
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms.
Cough: advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients ages 1 year and older) to help cough.[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[590]Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2020 Aug 18 [Epub ahead of print].
https://ebm.bmj.com/content/early/2020/07/28/bmjebm-2020-111336
http://www.ncbi.nlm.nih.gov/pubmed/32817011?tool=bestpractice.com
Olfactory dysfunction: consider treatment (e.g., olfactory training) if olfactory dysfunction persists beyond 2 weeks. Often it improves spontaneously and does not require specific treatment. There is no evidence to support the use of treatments in patients with COVID-19.[591]Whitcroft KL, Hummel T. Olfactory dysfunction in COVID-19: diagnosis and management. JAMA. 2020 May 20 [Epub ahead of print].
https://jamanetwork.com/journals/jama/fullarticle/2766523
http://www.ncbi.nlm.nih.gov/pubmed/32432682?tool=bestpractice.com
Supportive care
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Advise patients to improve air circulation by opening a window or door (fans can spread infection and should not be used).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Monitor
Closely monitor patients with risk factors for severe illness, and counsel patients about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Management of moderate COVID-19
Patients with suspected or confirmed moderate disease (i.e., clinical signs of pneumonia but no signs of severe pneumonia) should be isolated to contain virus transmission.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Location of care
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation, with telemedicine or remote visits as appropriate, can be considered in low-risk patients. Manage patients at high risk of deterioration in a healthcare facility.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Isolation period
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The CDC recommends discontinuing isolation once at least 10 days (not severely immunocompromised) or 20 days (severely immunocompromised) have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing home isolation once at least 10 days (not severely immunocompromised) or 20 days (severely immunocompromised) have passed since the date of a positive test. Alternatively, it recommends at least two negative RT-PCR tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[592]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
If the patient is isolated at home, the CDC guidance for discontinuing isolation is the same as for mild disease (see above).
Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients, and 10 days in patients with milder disease who are managed in the community. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[583]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication].
https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Infection prevention and control
Symptom management and supportive care
Antibiotics
Monitor
Closely monitor patients for signs or symptoms of disease progression.
If the patient is being managed at home, counsel them about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain). There is no evidence to support the use of pulse oximeters in the home setting.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
If the patient is being managed in hospital, monitor patients closely for signs of clinical deterioration using medical early warning scores (e.g., National Early Warning Score 2 [NEWS2]), and respond immediately with appropriate supportive care interventions.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Corticosteroids
The WHO does not recommend corticosteroids in patients with nonsevere disease as they may increase the risk of mortality in these patients.[575]World Health Organization. Therapeutics and COVID-19: living guideline. 2020 [internet publication].
https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline
In the UK, NHS England supports these guidelines, and does not recommend the use of corticosteroids in patients with nonsevere COVID-19.[593]NHS England. COVID-19 therapy: corticosteroids including dexamethasone and hydrocortisone. 2020 [internet publication].
https://www.england.nhs.uk/publication/covid-19-therapy-corticosteroids-including-dexamethasone-and-hydrocortisone/
Management of severe COVID-19
Patients with suspected or confirmed severe disease are at risk of rapid clinical deterioration.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Severe disease in adults is defined as having clinical signs of pneumonia plus at least one of the following:
Severe disease in children is defined as having clinical signs of pneumonia plus at least one of the following:
Central cyanosis or SpO₂ <90%
Severe respiratory distress
General danger signs: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions
Fast breathing (<2 months: ≥60 breaths per minute; 2-11 months: ≥50 breaths per minute; 1-5 years: ≥40 breaths per minute).
Location of care
Manage patients in an appropriate healthcare facility under the guidance of a specialist team.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
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 A meta-analysis found that an increase in CFS was associated with an increase in mortality (each 1-point increase in CFS was associated with a 12% increase in mortality).[594]Pranata R, Henrina J, Lim MA, et al. Clinical frailty scale and mortality in COVID-19: a systematic review and dose-response meta-analysis. Arch Gerontol Geriatr. 2020 Dec 15;93:104324.
https://www.sciencedirect.com/science/article/pii/S0167494320303216?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/33352430?tool=bestpractice.com
However, some studies suggest that a more nuanced understanding of frailty and outcomes is needed, and you should exercise caution in placing too much emphasis on the influence of frailty alone when discussing prognosis in older people.[595]Cosco TD, Best J, Davis D, et al. What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review. Age Ageing. 2021 Jan 14 [Epub ahead of print].
https://academic.oup.com/ageing/advance-article/doi/10.1093/ageing/afab008/6097011
http://www.ncbi.nlm.nih.gov/pubmed/33448278?tool=bestpractice.com
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.[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
Isolation period
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The CDC recommends discontinuing isolation once at least 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 20 days have passed since the date of a positive test. Alternatively, it recommends at least two negative RT-PCR tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[592]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[583]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication].
https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Infection prevention and control
Oxygen
Start supplemental oxygen therapy immediately in any patient with emergency signs (i.e., obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma and/or convulsions), or any patient without emergency signs and SpO₂ <90%.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
There is no evidence of benefit for oxygen therapy in patients with COVID-19 in the absence of hypoxemia.[596]Centre for Evidence-Based Medicine; Allsop M, Ziegler L, Fu Y, et al. Is oxygen an effective treatment option to alleviate the symptoms of breathlessness for patients dying with COVID-19 and what are the potential harms? 2020 [internet publication].
https://www.cebm.net/covid-19/is-oxygen-an-effective-treatment-option-to-alleviate-the-symptoms-of-breathlessness-for-patients-dying-with-covid-19-and-what-are-the-potential-harms/
Target SpO₂ to ≥94% during resuscitation in adults and children with emergency signs who require emergency airway management and oxygen therapy. Once the patient is stable, a target SpO₂ >90% in children and nonpregnant adults, and ≥92% to 95% in pregnant women is recommended. Nasal prongs or a nasal cannula are preferred in young children.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
Some centers may recommend different SpO₂ targets in order to support prioritization of oxygen flow for the most severely ill patients in hospital. NHS England recommends a target of 92% to 95% (or 90% to 94% if clinically appropriate), for example.[598]NHS England. Clinical guide for the optimal use of oxygen therapy during the coronavirus pandemic. 2020 [internet publication].
https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-oxygen-therapy.pdf
Consider positioning techniques (e.g., high supported sitting, prone position), and airway clearance management to assist with secretion clearance in adults.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Oxygen delivery can be increased by using a nonrebreathing mask and prone positioning.[599]Dondorp AM, Hayat M, Aryal D, et al. Respiratory support in novel coronavirus disease (COVID-19) patients, with a focus on resource-limited settings. Am J Trop Med Hyg. 2020 Apr 21 [Epub ahead of print].
http://www.ajtmh.org/content/journals/10.4269/ajtmh.20-0283
http://www.ncbi.nlm.nih.gov/pubmed/32319424?tool=bestpractice.com
Consider a trial of awake prone positioning to improve oxygenation in patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Early self-proning of awake, nonintubated patients has been shown to improve oxygen saturation and may delay or reduce the need for intensive care.[600]Caputo ND, Strayer RJ, Levitan R. Early self-proning in awake, non-intubated patients in the emergency department: a single ED's experience during the COVID-19 pandemic. Acad Emerg Med. 2020 May;27(5):375-8.
https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13994
http://www.ncbi.nlm.nih.gov/pubmed/32320506?tool=bestpractice.com
[601]Ng Z, Tay WC, Ho CHB. Awake prone positioning for non-intubated oxygen dependent COVID-19 pneumonia patients. Eur Respir J. 2020 May 26 [Epub ahead of print].
https://erj.ersjournals.com/content/early/2020/05/22/13993003.01198-2020
http://www.ncbi.nlm.nih.gov/pubmed/32457195?tool=bestpractice.com
[602]Golestani-Eraghi M, Mahmoodpoor A. Early application of prone position for management of Covid-19 patients. J Clin Anesth. 2020 May 26;66:109917.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247987/
http://www.ncbi.nlm.nih.gov/pubmed/32473503?tool=bestpractice.com
[603]Thompson AE, Ranard BL, Wei Y, et al. Prone positioning in awake, nonintubated patients with COVID-19 hypoxemic respiratory failure. JAMA Intern Med. 2020 Jun 17 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301298/
http://www.ncbi.nlm.nih.gov/pubmed/32584946?tool=bestpractice.com
[604]Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respir Med. 2020 Jun 19 [Epub ahead of print].
https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(20)30268-X.pdf
http://www.ncbi.nlm.nih.gov/pubmed/32569585?tool=bestpractice.com
Monitor patients closely for signs of progressive acute hypoxemic respiratory failure. Patients who continue to deteriorate despite standard oxygen therapy require advanced oxygen/ventilatory support.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Symptom management and supportive care
Fluids and electrolytes: use cautious fluid management in adults and children without tissue hypoperfusion and fluid responsiveness as aggressive fluid resuscitation may worsen oxygenation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Correct any electrolyte or metabolic abnormalities, such as hyperglycemia or metabolic acidosis, according to local protocols.[605]Mojoli F, Mongodi S, Orlando A, et al. Our recommendations for acute management of COVID-19. Crit Care. 2020 May 8;24(1):207.
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02930-6
http://www.ncbi.nlm.nih.gov/pubmed/32384909?tool=bestpractice.com
Fever and pain: acetaminophen or ibuprofen are recommended.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
There is no evidence at present of severe adverse events in COVID-19 patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilization, long-term survival, or quality of life in patients with COVID-19.[584]European Medicines Agency. EMA gives advice on the use of non-steroidal anti-inflammatories for COVID-19. 2020 [internet publication].
https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19
[585]US Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. 2020 [internet publication].
https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19
[586]Little P. Non-steroidal anti-inflammatory drugs and covid-19. BMJ. 2020 Mar 27;368:m1185.
https://www.bmj.com/content/368/bmj.m1185
http://www.ncbi.nlm.nih.gov/pubmed/32220865?tool=bestpractice.com
[587]Medicines and Healthcare products Regulatory Agency; Commission on Human Medicines. Commission on Human Medicines advice on ibuprofen and coronavirus (COVID-19). 2020 [internet publication].
https://www.gov.uk/government/news/commission-on-human-medicines-advice-on-ibuprofen-and-coronavirus-covid-19
[588]World Health Organization. The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19: scientific brief. 2020 [internet publication].
https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19
[589]National Institute for Health and Care Excellence. COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. 2020 [internet publication].
https://www.nice.org.uk/advice/es23/chapter/Key-messages
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms.
Cough: advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients ages 1 year and older) to help cough. Short-term use of a cough suppressant may be considered in select patients (e.g., if the cough is distressing to the patient) provided there are no contraindications.[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[590]Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2020 Aug 18 [Epub ahead of print].
https://ebm.bmj.com/content/early/2020/07/28/bmjebm-2020-111336
http://www.ncbi.nlm.nih.gov/pubmed/32817011?tool=bestpractice.com
Breathlessness: keep the room cool, and encourage relaxation, breathing techniques, and changing body positions. Identify and treat any reversible causes of breathlessness (e.g., pulmonary edema). Consider a trial of oxygen, if available. Consider an opioid and benzodiazepine combination in patients with moderate to severe breathlessness or patients who are distressed.[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Anxiety, delirium, and agitation: identify and treat any underlying or reversible causes (e.g., offer reassurance, treat hypoxia, correct metabolic or endocrine abnormalities, address coinfections, minimize use of drugs that may cause or worsen delirium, treat substance withdrawal, maintain normal sleep cycles, treat pain or breathlessness).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Consider a benzodiazepine for the management of anxiety or agitation that does not respond to other measures. Consider haloperidol or a phenothiazine for the management of delirium.[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Low doses of haloperidol (or another suitable antipsychotic) can also be considered for agitation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Nonpharmacologic interventions are the mainstay for the management of delirium when possible, and prevention is key.[606]Centre for Evidence-Based Medicine; Jones L, Candy B, Roberts N, et al. How can healthcare workers adapt non-pharmacological treatment – whilst maintaining safety – when treating people with COVID-19 and delirium? 2020 [internet publication].
https://www.cebm.net/covid-19/how-can-healthcare-workers-adapt-non-pharmacological-treatment-whilst-maintaining-safety-when-treating-people-with-covid-19-and-delirium/
Mouth care: an important part of overall patient care in hospitalized patients who are ventilated or nonventilated and those undergoing step-down or end-of-life care.[607]Public Health England. Mouth care for hospitalised patients with confirmed or suspected COVID-19. 2020 [internet publication].
https://www.gov.uk/government/publications/covid-19-mouth-care-for-patients-with-a-confirmed-or-suspected-case/mouth-care-for-hospitalised-patients-with-confirmed-or-suspected-covid-19
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia or depression as appropriate.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Venous thromboembolism prophylaxis
Assess the risk of bleeding as soon as possible after admission, or by the time of the first consultant review, using a suitable risk assessment tool.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
Start venous thromboembolism (VTE) prophylaxis in acutely ill hospitalized adults and adolescents with COVID-19 as per the standard of care for other hospitalized patients without COVID-19, provided there are no contraindications. A COVID-19 diagnosis should not influence a pediatrician’s recommendations about VTE prophylaxis in hospitalized children. Pregnant women should be managed by a specialist.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[609]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 May 21 [Epub ahead of print].
https://link.springer.com/article/10.1007/s11239-020-02138-z
http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
[610]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Jun 2 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/
http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
Start as soon as possible and within 14 hours of admission, and continue for the duration of the hospital stay or 7 days, whichever is longer.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
Low molecular weight heparin or fondaparinux are preferred over unfractionated heparin in order to reduce patient contact.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The National Institute for Health and Care Excellence in the UK recommends low molecular weight heparin first-line, with fondaparinux or unfractionated heparin reserved for patients who cannot have low molecular weight heparin.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
Unfractionated heparin is contraindicated in patients with severe thrombocytopenia. Fondaparinux is recommended in patients with a history of heparin-induced thrombocytopenia. Direct oral anticoagulants are not recommended. Mechanical thromboprophylaxis (e.g., intermittent pneumatic compression devices) is recommended if anticoagulation is contraindicated or not available.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[610]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Jun 2 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/
http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
[611]American Society Of Hematology. COVID-19 and VTE/anticoagulation: frequently asked questions. 2020 [internet publication].
https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation
The optimal dose is unknown. Standard prophylaxis doses are recommended over intermediate- or full treatment-dose regimens.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
[610]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Jun 2 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/
http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
Some clinicians are using intermediate- or full treatment-dose regimens rather than prophylactic doses as they are worried about undetected thrombi; however, this may lead to major bleeding events.[612]Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020 Apr 15 [Epub ahead of print].
https://www.sciencedirect.com/science/article/pii/S0735109720350087?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/32311448?tool=bestpractice.com
There are insufficient data to recommend increased anticoagulant doses for VTE prophylaxis in COVID-19 patients outside the setting of a clinical trial.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
However, some guidelines recommend that escalated doses can be considered in critically ill patients.[609]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 May 21 [Epub ahead of print].
https://link.springer.com/article/10.1007/s11239-020-02138-z
http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
[613]Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020 May;18(5):1023-6.
https://onlinelibrary.wiley.com/doi/full/10.1111/jth.14810
http://www.ncbi.nlm.nih.gov/pubmed/32338827?tool=bestpractice.com
The National Institute for Health and Care Excellence in the UK only recommends considering intermediate doses in patients who are having advanced respiratory support, and the decision should be based on multidisciplinary or senior opinion, or locally agreed protocols. Reassess VTE and bleeding risks daily in these patients.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
NHS England recommends that therapeutic doses should not be offered unless there is a standard indication for therapeutic anticoagulation, as trials show that therapeutic doses do not improve clinical outcome of severe disease in the critical care setting.[614]Medicines and Healthcare products Regulatory Agency. Therapeutic anticoagulation (heparin) in the management of severe COVID-19 (SARS-CoV-2 positive) patients. 2020 [internet publication].
https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103129
Dose adjustments may be required in patients with extremes of body weight or renal impairment.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
For patients who are already on an anticoagulant for another condition, continue the patient’s current therapeutic dose unless contraindicated by a change in clinical circumstances. Consider switching to low molecular weight heparin if the patient’s clinical condition is deteriorating and the patient is not currently on low molecular weight heparin.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
Monitor patients for signs and symptoms suggestive of thromboembolism and proceed with appropriate diagnostic and management pathways if clinically suspected.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
If the patient’s clinical condition changes, assess the risk of VTE, reassess the bleeding risk, and review VTE prophylaxis.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
Routine post-discharge VTE prophylaxis is not generally recommended, except in certain high-risk patients.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[609]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 May 21 [Epub ahead of print].
https://link.springer.com/article/10.1007/s11239-020-02138-z
http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
[610]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Jun 2 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/
http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
Ensure patients who require VTE prophylaxis after discharge are able to use it correctly or have arrangements made for someone to help them.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulation in hospitalized patients with COVID-19.[615]Flumignan RLG, de Sá Tinôco JD, Pascoal PIF, et al. Prophylactic anticoagulants for people hospitalised with COVID‐19. Cochrane Database Syst Rev. 2020 Oct 2:CD013739.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013739/full
A retrospective analysis of over 4000 patients found that anticoagulation was associated with lower mortality and intubation among hospitalized COVID-19 patients. Therapeutic anticoagulation was associated with lower mortality compared with prophylactic anticoagulation, but the difference was not statistically significant.[616]Nadkarni GN, Lala A, Bagiella E, et al. Anticoagulation, mortality, bleeding and pathology among patients hospitalized with COVID-19: a single health system study. J Am Coll Cardiol. 2020 Aug 24 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449655/
http://www.ncbi.nlm.nih.gov/pubmed/32860872?tool=bestpractice.com
Clinicians should rely on pre-COVID-19 evidence-based principles of anticoagulation management combined with rational approaches to address clinical challenges.[609]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 May 21 [Epub ahead of print].
https://link.springer.com/article/10.1007/s11239-020-02138-z
http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
Antimicrobials
Consider empiric antibiotics if there is clinical suspicion of bacterial infection. Give within 1 hour of initial assessment for patients with suspected sepsis or if the patient meets high-risk criteria (or within 4 hours of establishing a diagnosis of pneumonia); do not wait for microbiology results. Base the regimen on the clinical diagnosis (e.g., community-acquired pneumonia, hospital-acquired pneumonia, sepsis), local epidemiology and susceptibility data, and local treatment guidelines.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[528]National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng173
Some guidelines recommend empiric antibiotics for bacterial pathogens in all patients with community-acquired pneumonia without confirmed COVID-19. It is likely that the bacterial pathogens in patients with COVID-19 and pneumonia are the same as in previous patients with community-acquired pneumonia, and therefore empiric antimicrobial recommendations should be the same.[529]Metlay JP, Waterer GW. Treatment of community-acquired pneumonia during the coronavirus disease 2019 (COVID-19) pandemic. Ann Intern Med. 2020 Aug 18;173(4):304-5.
https://www.acpjournals.org/doi/10.7326/M20-2189
http://www.ncbi.nlm.nih.gov/pubmed/32379883?tool=bestpractice.com
However, the National Institute for Health and Care Excellence in the UK recommends that it is reasonable not to start empiric antimicrobials if you are confident that the clinical features are typical for COVID-19.[528]National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng173
There is insufficient evidence to recommend empiric broad-spectrum antimicrobials in the absence of another indication.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Some patients may require continued antibiotic therapy once COVID-19 has been confirmed depending on the clinical circumstances (e.g., clinical or microbiologic evidence of bacterial infection regardless of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] test results, SARS-CoV-2 test result is positive but clinical features are not typical for COVID-19). In these circumstances, review antibiotic choice based on microbiology results and switch to a narrower-spectrum antibiotic if appropriate, review intravenous antibiotic use within 48 hours and consider switching to oral therapy, and give for a total of 5 days unless there is a clear indication to continue.[528]National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng173
Reassess antibiotic use daily. De-escalate empiric therapy on the basis of microbiology results and clinical judgment. Regularly review the possibility of switching from intravenous to oral therapy. Duration of treatment should be as short as possible (e.g., 5 to 7 days). Antibiotic stewardship programs should be in place.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
A meta-analysis found that the prevalence of antibiotic prescribing in patients with COVID-19 was 75%, which is significantly higher than the estimated prevalence of bacterial coinfection. Therefore, unnecessary antibiotic use is likely to be high in these patients.[617]Langford BJ, So M, Raybardhan S, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect. 2021 Jan 5 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785281/
http://www.ncbi.nlm.nih.gov/pubmed/33418017?tool=bestpractice.com
Treat laboratory-confirmed coinfections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The treatment of influenza is the same in all patients regardless of SARS-CoV-2 coinfection. Start empiric treatment with oseltamivir in hospitalized patients who are suspected of having either or both infections as soon as possible without waiting for influenza test results. Antiviral therapy can be stopped once influenza has been ruled out.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Corticosteroids
The WHO strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with severe or critical disease. This recommendation is based on two meta-analyses that pooled data from eight randomized trials (over 7000 patients), including the UK RECOVERY trial. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical disease. They also probably reduce the need for invasive ventilation. There is no evidence directly comparing dexamethasone and hydrocortisone. The harms of treatment in this context are considered to be minor. It is unclear whether these recommendations can be applied to children or those who are immunocompromised. The WHO does not recommend corticosteroids in patients with nonsevere disease as they may increase the risk of mortality in these patients.[575]World Health Organization. Therapeutics and COVID-19: living guideline. 2020 [internet publication].
https://www.who.int/publications/i/item/therapeutics-and-covid-19-living-guideline
[618]WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group; Sterne JAC, Murthy S, Diaz JV, et al. Association between administration of systemic corticosteroids and mortality among critically ill patients with COVID-19: a meta-analysis. JAMA. 2020 Sep 2 [Epub ahead of print].
https://jamanetwork.com/journals/jama/article-abstract/2770279
http://www.ncbi.nlm.nih.gov/pubmed/32876694?tool=bestpractice.com
[619]Lamontagne F, Agoritsas T, Macdonald H, et al. A living WHO guideline on drugs for covid-19: update 3. BMJ. 2020 Dec 17;370:m3379.
https://www.bmj.com/content/370/bmj.m3379
There is also evidence that corticosteroids probably reduce the length of intensive care unit stay (low certainty), and increase ventilator-free days (moderate certainty).[620]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Drug treatments for covid-19: living systematic review and network meta-analysis. BMJ. 2020 Jul 30;370:m2980.
https://www.bmj.com/content/370/bmj.m2980
http://www.ncbi.nlm.nih.gov/pubmed/32732190?tool=bestpractice.com
[621]Siemieniuk RA, Bartoszko JJ, Ge L, et al. Update to living systematic review on drug treatments for covid-19. BMJ. 2020 Dec 17;371:m4852.
https://www.bmj.com/content/371/bmj.m4852
http://www.ncbi.nlm.nih.gov/pubmed/33334735?tool=bestpractice.com
In the UK, the National Institute for Health and Care Excellence recommends dexamethasone or hydrocortisone in patients with severe or critical COVID-19 (in line with WHO guidance). The marketing authorizations cover this indication in the UK.[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
NICE: COVID-19 prescribing brief – corticosteroids
external link opens in a new window
In Europe, the European Medicines Agency has endorsed the use of dexamethasone for patients with severe disease who require oxygen therapy or mechanical ventilation.[622]European Medicines Agency. EMA endorses use of dexamethasone in COVID-19 patients on oxygen or mechanical ventilation. 2020 [internet publication].
https://www.ema.europa.eu/en/news/ema-endorses-use-dexamethasone-covid-19-patients-oxygen-mechanical-ventilation
In the US, the National Institutes of Health guidelines panel recommends dexamethasone, either alone or in combination with remdesivir (see the Emerging section for information on remdesivir), in hospitalized patients who require supplemental oxygen. The panel recommends against using dexamethasone in patients who do not require supplemental oxygen. Alternative corticosteroids may be used in situations where dexamethasone is not available.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
The Infectious Diseases Society of America supports the use of dexamethasone in hospitalized patients with severe disease.[623]Bhimraj A, Morgan RL, Hirsch Shumaker A, et al. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. 2020 [internet publication].
https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/
Monitor patients for adverse effects (e.g., hyperglycemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Follow local policies on gastroprotection during corticosteroid treatment. Clinically significant interactions between remdesivir and corticosteroids are unlikely; however, lopinavir/ritonavir may increase hydrocortisone concentrations.[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
Monitor
Monitor patients closely for signs of clinical deterioration, and respond immediately with appropriate supportive care interventions.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Discharge and rehabilitation
Routinely assess older patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Palliative care
Management of critical COVID-19
Patients with critical disease (i.e., presence of acute respiratory distress syndrome, sepsis, or septic shock) should be admitted or transferred to an intensive/critical care unit.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Location of care
Manage patients in an intensive/critical care unit under the guidance of a specialist team.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Discuss the risks, benefits, and potential outcomes of treatment options with patients and their families, and allow them to express preferences about their management. Take their wishes and expectations into account when considering the ceiling of treatment. Use decision support tools if available. Put treatment escalation plans in place, and discuss any existing advance care plans or advance decisions to refuse treatment with patients who have preexisting advanced comorbidities.[574]National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng163
Isolation period
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The CDC recommends discontinuing isolation once at least 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 20 days have passed since the date of a positive test. Alternatively, it recommends at least two negative RT-PCR tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[592]Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with COVID-19 in healthcare settings (interim guidance). 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[583]Public Health England. Guidance for stepdown of infection control precautions and discharging COVID-19 patients. 2020 [internet publication].
https://www.gov.uk/government/publications/covid-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-covid-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-covid-19-patients
Infection prevention and control
High-flow nasal oxygen or noninvasive ventilation
Consider a trial of high-flow nasal oxygen (HFNO) or noninvasive ventilation (e.g., continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) in selected patients with mild acute respiratory distress syndrome (ARDS).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Airborne precautions are recommended for these interventions (including bubble CPAP) due to uncertainty about the potential for aerosolization.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Novel methods to protect clinicians without access to standard personal protective equipment during aerosol-generating procedures have been suggested.[624]Canelli R, Connor CW, Gonzalez M, et al. Barrier enclosure during endotracheal intubation. N Engl J Med. 2020 May 14;382(20):1957-8.
https://www.nejm.org/doi/full/10.1056/NEJMc2007589
http://www.ncbi.nlm.nih.gov/pubmed/32243118?tool=bestpractice.com
[625]Matava CT, Yu J, Denning S. Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19. Can J Anaesth. 2020 Apr 3 [Epub ahead of print].
https://link.springer.com/article/10.1007/s12630-020-01649-w
http://www.ncbi.nlm.nih.gov/pubmed/32246431?tool=bestpractice.com
[626]Lucchini A, Giani M, Isgrò S, et al. The "helmet bundle" in COVID-19 patients undergoing non invasive ventilation. Intensive Crit Care Nurs. 2020 Apr 2:102859.
https://www.sciencedirect.com/science/article/pii/S0964339720300628?via%3Dihub
http://www.ncbi.nlm.nih.gov/pubmed/32249028?tool=bestpractice.com
[627]Adir Y, Segol O, Kompaniets D, et al. Covid19: minimising risk to healthcare workers during aerosol producing respiratory therapy using an innovative constant flow canopy. Eur Respir J. 2020 Apr 20 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173679/
http://www.ncbi.nlm.nih.gov/pubmed/32312865?tool=bestpractice.com
Patients with hypercapnia, hemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, although emerging data suggests that it may be safe in patients with mild to moderate and nonworsening hypercapnia. Patients with hypoxemic respiratory failure and hemodynamic instability, multi-organ failure, or abnormal mental status should not receive these treatments in place of other options such as invasive ventilation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
There is ongoing debate about the optimal mode of respiratory support before mechanical ventilation.[628]McEnery T, Gough C, Costello RW. COVID-19: respiratory support outside the intensive care unit. Lancet Respir Med. 2020 Apr 9 [Epub ahead of print].
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30176-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32278367?tool=bestpractice.com
NHS England recommends CPAP as the preferred form of noninvasive ventilation in patients with hypoxemic (type 1) respiratory failure. It doesn't advocate the use of HFNO based on a lack of efficacy, oxygen use (HFNO can place a strain on oxygen supplies with the risk of site supply failure), and infection spread.[629]NHS England. Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected). 2020 [internet publication].
https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-NIV-respiratory-support-and-coronavirus.pdf
Other guidelines recommend HFNO over noninvasive ventilation, unless HFNO is not available.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
Despite the trend to avoid HFNO, it has been shown to have a similar risk of aerosol generation to standard oxygen masks.[630]Li J, Fink JB, Ehrmann S. High-flow nasal cannula for COVID-19 patients: low risk of bio-aerosol dispersion. Eur Respir J. 2020 May 14;55(5):2000892.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163690/
http://www.ncbi.nlm.nih.gov/pubmed/32299867?tool=bestpractice.com
Early CPAP may provide a bridge to invasive mechanical ventilation. Reserve the use of BiPAP for patients with hypercapnic acute on chronic ventilatory failure (type 2 respiratory failure).[629]NHS England. Guidance for the role and use of non-invasive respiratory support in adult patients with COVID19 (confirmed or suspected). 2020 [internet publication].
https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/specialty-guide-NIV-respiratory-support-and-coronavirus.pdf
Indirect and low-certainty evidence suggests that noninvasive ventilation probably reduces mortality in patients with COVID-19, similar to mechanical ventilation, but may increase the risk of viral transmission.[631]Schünemann HJ, Khabsa J, Solo K, et al. Ventilation techniques and risk for transmission of coronavirus disease, including COVID-19. Ann Intern Med. 2020 May 22 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/M20-2306
http://www.ncbi.nlm.nih.gov/pubmed/32442035?tool=bestpractice.com
[632]Thomas R, Lotfi T, Morgano GP, et al. Update alert 2: ventilation techniques and risk for transmission of coronavirus disease, including COVID-19. Ann Intern Med. 2020 Oct 13 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/L20-1211
http://www.ncbi.nlm.nih.gov/pubmed/33045175?tool=bestpractice.com
Monitor patients closely for acute deterioration. If patients do not improve after a short trial of these interventions they require urgent endotracheal intubation.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
More detailed guidance on the management of ARDS in COVID-19 is beyond the scope of this topic; consult a specialist for further guidance.
Mechanical ventilation
Consider endotracheal intubation and invasive mechanical ventilation in patients who are acutely deteriorating despite advanced oxygen/noninvasive ventilatory support measures.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Two-thirds of patients who required critical care in the UK had mechanical ventilation within 24 hours of admission.[633]Mahase E. Covid-19: most patients require mechanical ventilation in first 24 hours of critical care. BMJ. 2020 Mar 24;368:m1201.
https://www.bmj.com/content/368/bmj.m1201
http://www.ncbi.nlm.nih.gov/pubmed/32209544?tool=bestpractice.com
In New York, 33% of hospitalized patients developed respiratory failure leading to mechanical ventilation. These patients were more likely to be male, have obesity, and have elevated inflammatory markers and liver function tests.[388]Goyal P, Choi JJ, Pinheiro LC, et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med. 2020 Jun 11;382(24):2372-4.
https://www.nejm.org/doi/full/10.1056/NEJMc2010419
http://www.ncbi.nlm.nih.gov/pubmed/32302078?tool=bestpractice.com
Patients spent an average of 18 days on a ventilator (range 9-28 days).[634]Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020 Jun 6;395(10239):1763-70.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237188/
http://www.ncbi.nlm.nih.gov/pubmed/32442528?tool=bestpractice.com
Patients who required invasive mechanical ventilation had an 36% to 88% mortality rate in studies.[635]Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020 Apr 22;323(20):2052-9.
https://jamanetwork.com/journals/jama/fullarticle/2765184
http://www.ncbi.nlm.nih.gov/pubmed/32320003?tool=bestpractice.com
[636]Docherty AB, Harrison EM, Green CA, et al; medRxiv. Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. 2020 [internet publication].
https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1
[637]Auld SC, Caridi-Scheible M, Blum JM, et al. ICU and ventilator mortality among critically ill adults with coronavirus disease 2019. Crit Care Med. 2020 May 26 [Epub ahead of print].
https://journals.lww.com/ccmjournal/Abstract/9000/ICU_and_Ventilator_Mortality_Among_Critically_Ill.95639.aspx
http://www.ncbi.nlm.nih.gov/pubmed/32452888?tool=bestpractice.com
Endotracheal intubation should be performed by an experienced provider using airborne precautions.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Intubation by video laryngoscopy is recommended if possible.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Young children, or adults who are obese or pregnant, may desaturate quickly during intubation and therefore require preoxygenation with 100% FiO₂ for 5 minutes.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Mechanically ventilated patients with ARDS 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 in moderate to severe ARDS. However, individualization of PEEP, where the patient is monitored for beneficial or harmful effects and driving pressure during titration with consideration of the risks and benefits of PEEP titration, is recommended.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
NHS England recommends a low PEEP strategy in patients with normal compliance where recruitment may not be required.[638]NHS England. Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic. 2020 [internet publication].
https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/Specialty-guide_Adult-critical-care.pdf
Although some patients with COVID-19 pneumonia meet the criteria for ARDS, there is some discussion about whether COVID-19 pneumonia is its own specific disease with atypical phenotypes. Anecdotal evidence suggests that the main characteristic of the atypical presentation is the dissociation between well-preserved lung mechanics and the severity of hypoxemia.[639]Gattinoni L, Coppola S, Cressoni M, et al. Covid-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299-300.
https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE
http://www.ncbi.nlm.nih.gov/pubmed/32228035?tool=bestpractice.com
[640]Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Crit Care. 2020 Apr 16;24(1):154.
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02880-z
http://www.ncbi.nlm.nih.gov/pubmed/32299472?tool=bestpractice.com
[641]Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med. 2020 Apr 14 [Epub ahead of print].
https://link.springer.com/article/10.1007%2Fs00134-020-06033-2
http://www.ncbi.nlm.nih.gov/pubmed/32291463?tool=bestpractice.com
[642]Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020 Apr 24 [Epub ahead of print].
https://jamanetwork.com/journals/jama/fullarticle/2765302
http://www.ncbi.nlm.nih.gov/pubmed/32329799?tool=bestpractice.com
[643]Rello J, Storti E, Belliato M, et al. Clinical phenotypes of SARS-CoV-2: implications for clinicians and researchers. Eur Respir J. 2020 Apr 27 [Epub ahead of print].
https://erj.ersjournals.com/content/early/2020/04/20/13993003.01028-2020
http://www.ncbi.nlm.nih.gov/pubmed/32341111?tool=bestpractice.com
[644]Tsolaki V, Siempos I, Magira E, et al. PEEP levels in COVID-19 pneumonia. Crit Care. 2020 Jun 6;24(1):303.
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03049-4
http://www.ncbi.nlm.nih.gov/pubmed/32505186?tool=bestpractice.com
However, this approach has been criticized.[645]Bos LD, Paulus F, Vlaar APJ, et al. Subphenotyping ARDS in COVID-19 patients: consequences for ventilator management. Ann Am Thorac Soc. 2020 May 12 [Epub ahead of print].
https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.202004-376RL
http://www.ncbi.nlm.nih.gov/pubmed/32396457?tool=bestpractice.com
[646]Jain A, Doyle DJ. Stages or phenotypes? A critical look at COVID-19 pathophysiology. Intensive Care Med. 2020 May 18;:1-2.
https://link.springer.com/article/10.1007%2Fs00134-020-06083-6
http://www.ncbi.nlm.nih.gov/pubmed/32425310?tool=bestpractice.com
It has been argued that an evidence-based approach extrapolating data from ARDS not related to COVID-19 is the most reasonable approach for intensive care of COVID-19 patients.[647]Rice TW, Janz DR. In defense of evidence-based medicine for the treatment of COVID-19 ARDS. Ann Am Thorac Soc. 2020 Apr 22 [Epub ahead of print].
https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.202004-325IP
http://www.ncbi.nlm.nih.gov/pubmed/32320268?tool=bestpractice.com
As a consequence of this, some clinicians have warned that protocol-driven ventilator use may be causing lung injury in some patients, and that ventilator settings should be based on physiologic findings rather than using standard protocols. High PEEP may have a detrimental effect on patients with normal compliance.[639]Gattinoni L, Coppola S, Cressoni M, et al. Covid-19 does not lead to a "typical" acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020 May 15;201(10):1299-300.
https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0817LE
http://www.ncbi.nlm.nih.gov/pubmed/32228035?tool=bestpractice.com
PEEP should always be carefully titrated.[599]Dondorp AM, Hayat M, Aryal D, et al. Respiratory support in novel coronavirus disease (COVID-19) patients, with a focus on resource-limited settings. Am J Trop Med Hyg. 2020 Apr 21 [Epub ahead of print].
http://www.ajtmh.org/content/journals/10.4269/ajtmh.20-0283
http://www.ncbi.nlm.nih.gov/pubmed/32319424?tool=bestpractice.com
Consider prone ventilation in patients with severe ARDS for 12 to 16 hours per day. Pregnant women in the third trimester may benefit from being placed in the lateral decubitus position. Caution is required in children.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
Longer durations may be feasible in some patients.[648]Carsetti A, Damia Paciarini A, Marini B, et al. Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and effective. Crit Care. 2020 May 15;24(1):225.
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02956-w
http://www.ncbi.nlm.nih.gov/pubmed/32414420?tool=bestpractice.com
A small cohort study of 12 patients in Wuhan City, China, with COVID-19-related ARDS suggests that spending periods of time in the prone position may improve lung recruitability.[649]Pan C, Chen L, Lu C, et al. Lung recruitability in SARS-CoV-2 associated acute respiratory distress syndrome: a single-center, observational study. Am J Respir Crit Care Med. 2020 May 15;201(10):1294-7.
https://www.atsjournals.org/doi/abs/10.1164/rccm.202003-0527LE
http://www.ncbi.nlm.nih.gov/pubmed/32200645?tool=bestpractice.com
Two small case series found that many people tolerate the prone position while awake, breathing spontaneously, or receiving noninvasive ventilation. In the patients who tolerated it, improvement in oxygenation and a decrease in respiratory rate occurred.[650]Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020 May 15 [Epub ahead of print].
https://jamanetwork.com/journals/jama/fullarticle/2766291
http://www.ncbi.nlm.nih.gov/pubmed/32412606?tool=bestpractice.com
[651]Elharrar X, Trigui Y, Dols AM, et al. Use of prone positioning in nonintubated patients with COVID-19 and hypoxemic acute respiratory failure. JAMA. 2020 May 15 [Epub ahead of print].
https://jamanetwork.com/journals/jama/fullarticle/2766292
http://www.ncbi.nlm.nih.gov/pubmed/32412581?tool=bestpractice.com
Lung recruitment maneuvers are suggested, but staircase recruitment maneuvers are not recommended.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
More detailed guidance on the management of ARDS in COVID-19, including sedation and the use of neuromuscular blockade during ventilation, is beyond the scope of this topic; consult a specialist for further guidance.
Inhaled pulmonary vasodilator
Consider a trial of an inhaled pulmonary vasodilator in adults who have severe ARDS and hypoxemia despite optimizing ventilation. Taper off if there is no rapid improvement in oxygenation.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
Extracorporeal membrane oxygenation
Consider extracorporeal membrane oxygenation (ECMO) according to availability and expertise if the above methods fail.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[597]Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020 May;46(5):854-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101866/
http://www.ncbi.nlm.nih.gov/pubmed/32222812?tool=bestpractice.com
[652]American Thoracic Society. Diagnosis and management of COVID-19 disease. 2020 [internet publication].
https://www.thoracic.org/patients/patient-resources/resources/covid-19-diagnosis-and-mgmt.pdf
[653]Ramanathan K, Antognini D, Combes A, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Respir Med. 2020 May;8(5):518-26.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102637/
http://www.ncbi.nlm.nih.gov/pubmed/32203711?tool=bestpractice.com
ECMO is not suitable for all patients, and only those who meet certain inclusion criteria may be considered for ECMO.[654]NHS England. Clinical guide for extra corporeal membrane oxygenation (ECMO) for respiratory failure in adults during the coronavirus pandemic. 2020 [internet publication].
https://www.nice.org.uk/Media/Default/About/COVID-19/Specialty-guides/Speciality-Guide-Extra-Corporeal-Membrane-Oxygenation-ECMO-Adult.pdf
There is insufficient evidence to recommend either for or against the routine use of ECMO.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
The estimated 60-day survival rate of ECMO-rescued patients with COVID-19 (31%) was similar to that of previous studies of ECMO for severe ARDS.[655]Schmidt M, Hajage D, Lebreton G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study. Lancet Respir Med. 2020 Aug 13 [Epub ahead of print].
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30328-3/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32798468?tool=bestpractice.com
An international cohort study of 1035 patients found that both the estimated mortality 90 days after ECMO initiation and mortality in those who achieved a final outcome of death or discharge were <40%, consistent with previously reported survival rates in acute hypoxemic respiratory failure.[656]Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet. 2020 Sep 25 [Epub ahead of print].
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32008-0/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32987008?tool=bestpractice.com
Single-access, dual-stage venovenous ECMO with early extubation appears to be safe and effective in patients with COVID-19 respiratory failure.[657]Mustafa AK, Alexander PJ, Joshi DJ, et al. Extracorporeal membrane oxygenation for patients with COVID-19 in severe respiratory failure. JAMA Surg. 2020 Aug 11 [Epub ahead of print].
https://jamanetwork.com/journals/jamasurgery/fullarticle/2769429
http://www.ncbi.nlm.nih.gov/pubmed/32780089?tool=bestpractice.com
Management of septic shock/sepsis
Symptom management and supportive care
Consider fluid and electrolyte management, antimicrobial treatment, VTE prophylaxis, and symptom management as appropriate (see above).
As with severe disease, guidelines recommend low molecular weight heparin as the preferred option for VTE prophylaxis. However, unfractionated heparin is preferred over fondaparinux in critically ill patients if low molecular weight heparin cannot be used.[610]Moores LK, Tritschler T, Brosnahan S, et al. Prevention, diagnosis, and treatment of VTE in patients with coronavirus disease 2019: CHEST guideline and expert panel report. Chest. 2020 Jun 2 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265858/
http://www.ncbi.nlm.nih.gov/pubmed/32502594?tool=bestpractice.com
Some guidelines recommend that escalated doses can be considered in critically ill patients.[609]Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the Anticoagulation Forum. J Thromb Thrombolysis. 2020 May 21 [Epub ahead of print].
https://link.springer.com/article/10.1007/s11239-020-02138-z
http://www.ncbi.nlm.nih.gov/pubmed/32440883?tool=bestpractice.com
[613]Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020 May;18(5):1023-6.
https://onlinelibrary.wiley.com/doi/full/10.1111/jth.14810
http://www.ncbi.nlm.nih.gov/pubmed/32338827?tool=bestpractice.com
The National Institute for Health and Care Excellence in the UK only recommends considering intermediate doses in patients who are having advanced respiratory support, and the decision should be based on multidisciplinary or senior opinion, or locally agreed protocols. Reassess VTE and bleeding risks daily in these patients.[608]National Institute for Health and Care Excellence. COVID-19 rapid guideline: reducing the risk of venous thromboembolism in over 16s with COVID-19. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng186
NHS England recommends that therapeutic doses should not be offered unless there is a standard indication for therapeutic anticoagulation, as trials show that therapeutic doses do not improve clinical outcome of severe disease in the critical care setting.[658]Medicines and Healthcare products Regulatory Agency. Therapeutic anticoagulation (heparin) in the management of severe COVID-19 (SARS-CoV-2 positive) patients. 2020 [internet publication].
https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103129
Corticosteroids
Consider systemic corticosteroids for the management of critically ill patients (see above). In the US, the National Institutes of Health guidelines panel recommends dexamethasone, either alone or in combination with remdesivir, in hospitalized patients who require high-flow oxygen or noninvasive ventilation. The panel recommends dexamethasone alone in patients on mechanical ventilation or ECMO.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
Discharge and rehabilitation
Routinely assess intensive care patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Palliative care
Management of pregnant women
Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as midwifery and mental health and psychosocial support. A woman-centered, respectful, skilled approach to care is recommended.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
In women with severe or critical disease, the multidisciplinary team should be organized as soon as possible after maternal hypoxemia occurs in order to assess fetal maturity, disease progression, and the best options for delivery.[659]Chen L, Jiang H, Zhao Y. Pregnancy with Covid-19: management considerations for care of severe and critically ill cases. Am J Reprod Immunol. 2020 Jul 4:e13299.
https://onlinelibrary.wiley.com/doi/10.1111/aji.13299
http://www.ncbi.nlm.nih.gov/pubmed/32623810?tool=bestpractice.com
There are limited data available on the management of pregnant women with COVID-19; however, pregnant women can generally be treated with the same supportive therapies detailed above, taking into account the physiologic changes that occur with pregnancy.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The prevalence of asymptomatic SARS-CoV-2-positive pregnant women admitted for delivery appears to be low (<3% in a cohort in Connecticut, and 0.43% in a cohort in California).[660]Campbell KH, Tornatore JM, Lawrence KE, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in Southern Connecticut. JAMA. 2020 May 26 [Epub ahead of print].
https://jamanetwork.com/journals/jama/fullarticle/2766650
http://www.ncbi.nlm.nih.gov/pubmed/32453390?tool=bestpractice.com
[661]Fassett MJ, Lurvey LD, Yasumura L, et al. Universal SARS-Cov-2 screening in women admitted for delivery in a large managed care organization. Am J Perinatol. 2020 Jul 3 [Epub ahead of print].
https://www.thieme-connect.de/products/ejournals/html/10.1055/s-0040-1714060
http://www.ncbi.nlm.nih.gov/pubmed/32620022?tool=bestpractice.com
Screening women and their delivery partners before admission may not be helpful. More than 15% of asymptomatic maternity patients tested positive for SARS-CoV-2 infection despite having been screened negative using a telephone screening tool in one small observational study in New York. In addition to this, 58% of their asymptomatic support persons tested positive despite being screened negative.[662]Bianco A, Buckley AB, Overbey J, et al. Testing of patients and support persons for coronavirus disease 2019 (COVID-19) infection before scheduled deliveries. Obstet Gynecol. 2020 May 19 [Epub ahead of print].
https://journals.lww.com/greenjournal/Abstract/9000/Testing_of_Patients_and_Support_Persons_for.97342.aspx
http://www.ncbi.nlm.nih.gov/pubmed/32433448?tool=bestpractice.com
Another study in a New York obstetric population found that 88% of women who tested positive for SARS-CoV-2 at admission were asymptomatic at presentation.[663]Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020 Apr 13 [Epub ahead of print].
https://www.nejm.org/doi/full/10.1056/NEJMc2009316
http://www.ncbi.nlm.nih.gov/pubmed/32283004?tool=bestpractice.com
Location of care
Manage pregnant women in a healthcare facility, in a community facility, or at home. Women with suspected or confirmed mild disease may not require acute care in a hospital unless there is concern for rapid deterioration or an inability to return to hospital promptly.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Follow local infection prevention and control procedures as for nonpregnant people.
Consider home care in women with asymptomatic or mild illness, provided the patient has no signs of potentially severe illness (e.g., breathlessness, hemoptysis, new chest pain/pressure, anorexia, dehydration, confusion), no comorbidities, and no obstetric issues; the patient is able to care for herself; and monitoring and follow-up is possible. Otherwise, manage pregnant women in a hospital setting with appropriate maternal and fetal monitoring whenever possible.[461]Poon LC, Yang H, Kapur A, et al. Global interim guidance on coronavirus disease 2019 (COVID‐19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. 2020 [internet publication].
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.13156
[664]American College of Obstetricians and Gynecologists. Novel coronavirus 2019 (COVID-19). 2020 [internet publication].
https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
[665]Favre G, Pomar L, Qi X, et al. Guidelines for pregnant women with suspected SARS-CoV-2 infection. Lancet Infect Dis. 2020 Mar 3 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30157-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32142639?tool=bestpractice.com
Postpone routine prenatal or postpartum health visits for women who are in home isolation and reschedule them after the isolation period is completed. Delivery of counseling and care should be conducted via telemedicine whenever possible. Counsel women about healthy diet, mobility and exercise, intake of micronutrients, smoking, and alcohol and substance use. Advise women to seek urgent care if they develop any worsening of illness or danger signs, or danger signs of pregnancy.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The American College of Obstetricians and Gynecologists has published an algorithm to help decide whether hospital admission or home care is more appropriate.
ACOG: outpatient assessment and management for pregnant women with suspected or confirmed novel coronavirus (COVID-19)
external link opens in a new window
Prenatal corticosteroids
Consider prenatal corticosteroids for fetal lung maturation in women who are at risk of preterm birth (24 to 37 weeks’ gestation). Caution is advised because corticosteroids could potentially worsen the maternal clinical condition, and the decision should be made in conjunction with the multidisciplinary team.[461]Poon LC, Yang H, Kapur A, et al. Global interim guidance on coronavirus disease 2019 (COVID‐19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. 2020 [internet publication].
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.13156
[665]Favre G, Pomar L, Qi X, et al. Guidelines for pregnant women with suspected SARS-CoV-2 infection. Lancet Infect Dis. 2020 Mar 3 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30157-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32142639?tool=bestpractice.com
[666]Chen D, Yang H, Cao Y, et al. Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection. Int J Gynaecol Obstet. 2020 May;149(2):130-6.
http://www.ncbi.nlm.nih.gov/pubmed/32196655?tool=bestpractice.com
The WHO recommends prenatal corticosteroids only when there is no clinical evidence of maternal infection and adequate childbirth and newborn care is available, and in women with mild COVID-19 after assessing the risks and benefits.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
There is no evidence that corticosteroids in the doses prescribed for fetal lung maturation cause any harm in the context of COVID-19, but there is also no evidence of safety. The unknown effect on maternal outcome should be weighed against the neonatal benefit, particularly at later preterm gestations.[667]Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection in pregnancy: information for healthcare professionals. 2020 [internet publication].
https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf
Treatments
Most clinical trials to date have excluded pregnant women. However, potentially effective treatments should not be withheld from pregnant women due to theoretical concerns about the safety of these therapeutic agents in pregnancy. Decisions should be made with a shared decision-making process between the patient and the clinical team.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
There is no convincing evidence that systemic corticosteroids increase the incidence of congenital abnormalities. The benefits of corticosteroids in pregnant or breastfeeding women with severe or critical disease are thought to outweigh the risks.[573]National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults. 2020 [internet publication].
https://www.nice.org.uk/guidance/ng159
VTE prophylaxis
The National Institutes of Health recommends prophylactic dose anticoagulation in pregnant women who are hospitalized with severe disease, provided there are no contraindications to its use. Anticoagulation during labor and delivery requires specialized care and planning, and should be managed in a similar way to pregnant women with other conditions that require anticoagulation. VTE prophylaxis after discharge is not recommended.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/
The Royal College of Obstetricians and Gynaecologists (RCOG) has also published guidance on the prevention of VTE in pregnant women.[667]Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection in pregnancy: information for healthcare professionals. 2020 [internet publication].
https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf
Labor and delivery
Implement local infection prevention and control measures during labor and delivery. A negative pressure isolation room is recommended if available. Screen birth partners for COVID-19 infection using the standard case definition.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Individualize mode of birth based on obstetric indications and the woman’s preferences. Vaginal delivery is preferred in women with confirmed infection to avoid unnecessary surgical complications. Induction of labor, interventions to accelerate labor and delivery, and cesarean delivery are generally only recommended when medically justified based on maternal and fetal condition. COVID-19 positive status alone is not an indication for cesarean section.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
[461]Poon LC, Yang H, Kapur A, et al. Global interim guidance on coronavirus disease 2019 (COVID‐19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. 2020 [internet publication].
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.13156
[665]Favre G, Pomar L, Qi X, et al. Guidelines for pregnant women with suspected SARS-CoV-2 infection. Lancet Infect Dis. 2020 Mar 3 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30157-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/32142639?tool=bestpractice.com
Avoid using birthing pools in patients with suspected or confirmed infection.[667]Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection in pregnancy: information for healthcare professionals. 2020 [internet publication].
https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf
Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes. The risk of transmission via blood is thought to be minimal, and there is no evidence that delayed cord clamping increases the risk of viral transmission from the mother to the newborn.[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
Consider babies born to mothers with suspected or confirmed infection to be a person under investigation and isolate them from healthy newborns. Test them for infection 24 hours after birth, and, if negative, again 48 hours after birth.[668]American Academy of Pediatrics. Management of infants born to mothers with suspected or confirmed COVID-19. 2020 [internet publication].
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/
Newborn care
Experts are divided on separating mother and baby after delivery; make decisions on a case-by-base basis using shared-decision making.
A retrospective cohort analysis, the largest series to date, found no clinical evidence of vertical transmission in 101 newborns born to mothers with suspected or confirmed SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices. This suggests that separation may not be warranted and breastfeeding appears to be safe.[669]Dumitriu D, Emeruwa UN, Hanft E, et al. Outcomes of neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection at a large medical center in New York City. JAMA Pediatr. 2020 Oct 12 [Epub ahead of print].
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2771636
http://www.ncbi.nlm.nih.gov/pubmed/33044493?tool=bestpractice.com
The WHO recommends that mothers and infants should remain together unless the mother is too sick to care for her baby. 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).[2]World Health Organization. Clinical management of COVID-19: interim guidance. 2020 [internet publication].
https://www.who.int/publications-detail/clinical-management-of-covid-19
The WHO advises that the benefits of breastfeeding outweigh the potential risks for transmission.[670]World Health Organization. Breastfeeding and COVID-19: scientific brief. 2020 [internet publication].
https://www.who.int/publications/i/item/10665332639
Mother-to-infant transmission appears to be rare during rooming-in, provided that adequate droplet and contact precautions are taken.[671]Ronchi A, Pietrasanta C, Zavattoni M, et al. Evaluation of rooming-in practice for neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection in Italy. JAMA Pediatr. 2020 Dec 7 [Epub ahead of print].
https://jamanetwork.com/journals/jamapediatrics/fullarticle/2773311
http://www.ncbi.nlm.nih.gov/pubmed/33284345?tool=bestpractice.com
The CDC recommends that temporary separation of a newborn from a mother with confirmed or suspected COVID-19 may be considered after weighing the risks and benefits as current evidence suggests the risk of a neonate acquiring infection from its mother is low; healthcare providers should respect maternal autonomy in the medical decision-making process. If separation is not undertaken, measures to minimize the risk of transmission should be implemented.[672]Centers for Disease Control and Prevention. Evaluation and management considerations for neonates at risk for COVID-19. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html
A mother with confirmed infection should be counseled to take all possible precautions to avoid transmission to the infant during breastfeeding (e.g., hand hygiene, wearing a cloth face covering). Expressed milk should be fed to the newborn by a healthy caregiver.[673]Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): care for breastfeeding women. 2020 [internet publication].
https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html
The RCOG recommends that mothers with confirmed infection and healthy babies are kept together in the immediate postpartum period. It is recommended that the risks and benefits are discussed with neonatologists and families in order to individualize care in babies who may be more susceptible to infection. The RCOG advises that the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breast milk, and recommends appropriate preventive precautions to limit transmission to the baby.[667]Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection in pregnancy: information for healthcare professionals. 2020 [internet publication].
https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-14-coronavirus-covid-19-infection-in-pregnancy-v12.pdf
The American Academy of Pediatrics (AAP) recommends that temporary separation is the safest option, but acknowledges there are situations where this is not possible or the mother chooses to room-in. The AAP supports breastfeeding as the best choice for feeding. Breast milk can be expressed after appropriate hygiene measures and fed by an uninfected caregiver. If the mother chooses to breastfeed the infant themselves, appropriate prevention measures are recommended. After discharge, advise mothers with COVID-19 to practice prevention measures (e.g., distance, hand hygiene, respiratory hygiene/mask) for newborn care until either: they are afebrile for 72 hours without use of antipyretics and at least 10 days have passed since symptoms first appeared; or they have at least two consecutive negative SARS-CoV-2 tests from specimens collected ≥24 hours apart. This may require the support of an uninfected caregiver. A newborn with documented infection requires close outpatient follow-up after discharge for 14 days after birth.[668]American Academy of Pediatrics. Management of infants born to mothers with suspected or confirmed COVID-19. 2020 [internet publication].
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/
Management of people living with HIV
Recommendations for the triage, management, and treatment of COVID-19 in people with HIV are the same as those for the general population. Continue antiretroviral therapy and prophylaxis for opportunistic infections whenever possible, including patients who require hospitalization. Consult with a HIV specialist before adjusting or switching antiretroviral medications, and pay attention to potential drug-drug interactions and overlapping toxicities with COVID-19 treatments.[3]National Institutes of Health. Coronavirus disease 2019 (COVID-19) treatment guidelines. 2020 [internet publication].
https://covid19treatmentguidelines.nih.gov/