Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
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]
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][3] This decision requires careful clinical judgment and should be informed by an assessment of the patient’s home environment.[485] The location of care will depend on guidance from local health authorities and available resources.
Pregnant 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]
Advise patients and household members to follow appropriate infection prevention and control measures:
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] 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.[510] If the patient is hospitalized, 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 isolation period is 10 days in patients with milder disease who are managed in the community.[511]
Treatment recommended for ALL patients in selected patient group
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.[503]
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.[2]
Advise patients to improve air circulation by opening a window or door (fans can spread infection and should not be used).[503]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[519]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][512] 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][503][513][514][515][516][517][518]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
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]
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 and pregnant women in a healthcare facility.[2][3]
Implement local infection prevention and control procedures when managing patients with COVID-19. For patients in home isolation, advise patients and household members to follow appropriate infection prevention and control measures:
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] The Centers for Disease Control and Prevention (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 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 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. A symptom-based strategy is preferred in these patients.[520] If the patient is isolated at home, 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.[511]
Treatment recommended for ALL patients in selected patient group
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). 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]
Treatment recommended for ALL patients in selected patient group
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.[503]
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.[2]
Advise patients to improve air circulation by opening a window or door (fans can spread infection and should not be used).[503]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[519]
Treatment recommended for SOME patients in selected patient group
Consider empiric antibiotics if there is clinical suspicion of bacterial infection.[2][3] Antibiotics may also be considered in older people (particularly those in long-term care facilities) and children <5 years of age to provide empiric antibiotic treatment for possible pneumonia. The regimen should be based on the clinical diagnosis, local epidemiology and susceptibility data, and local treatment guidelines.[2]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][512] 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][503][513][514][515][516][517][518]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
Patients with suspected or confirmed severe disease are at risk of rapid clinical deterioration and should be admitted to an appropriate healthcare facility under the guidance of a specialist team. Severe disease in adults is defined as having clinical signs of pneumonia plus at least one of the following: respiratory rate >30 breaths/minute, severe respiratory distress, or SpO₂ <90% on room air. 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 sign, inability to breastfeed or drink, lethargy or unconsciousness, or convulsions).[2]
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 Involve critical care teams in discussions about admission to critical care.[502] A large observational study found that disease outcomes were better predicted by frailty than either age or comorbidity; frailty (CFS score 5-8) was associated with earlier death and longer duration of hospital stay, and these outcomes worsened with increasing frailty after adjustment for age and comorbidity.[521]
Implement local infection prevention and control procedures when managing patients with COVID-19.
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] 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.[570]
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] The Centers for Disease Control and Prevention (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 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. A symptom-based strategy is preferred in these patients.[520] 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.[511]
Treatment recommended for ALL patients in selected patient group
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][3]
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] Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[512]
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.[523]
Consider positioning techniques (e.g., high supported sitting, prone position), and airway clearance management to assist with secretion clearance in adults.[2] Oxygen delivery can be increased by using a nonrebreathing mask and prone positioning.[524] 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] Early self-proning of awake, nonintubated patients has been shown to improve oxygen saturation and may delay or reduce the need for intensive care.[525][526][527][528][529]
Monitor patients closely for signs of progressive acute hypoxemic respiratory failure.[2][3]
Treatment recommended for ALL patients in selected patient group
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] Correct any electrolyte or metabolic abnormalities, such as hyperglycemia or metabolic acidosis, according to local protocols.[530]
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.[503]
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.[503]
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][503] 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.[503] Low doses of haloperidol (or another suitable antipsychotic) can also be considered for agitation.[2] Nonpharmacologic interventions are the mainstay for the management of delirium when possible, and prevention is key.[531]
Mental health symptoms: provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]
Treatment recommended for ALL patients in selected patient group
Primary options
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
OR
fondaparinux: consult specialist for guidance on dose
Secondary options
heparin: consult specialist for guidance on dose
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][3][532][533]
Low molecular weight heparin or fondaparinux are preferred over unfractionated heparin in order to reduce patient contact. 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][533][534]
The optimal dose is unknown. Standard prophylaxis doses are recommended over intermediate- or full treatment-dose regimens.[533] 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.[535] There are insufficient data to recommend increased anticoagulant doses for VTE prophylaxis in COVID-19 patients outside the setting of a clinical trial.[3] However, some guidelines recommend that escalated doses can be considered in critically ill patients.[532]
Monitor patients for signs and symptoms suggestive of thromboembolism and proceed with appropriate diagnostic and management pathways if clinically suspected.[2]
Routine post-discharge VTE prophylaxis is not generally recommended, except in certain high-risk patients.[3][532][533]
There is little high-quality evidence for VTE prophylaxis in COVID-19 patients; therefore, clinicians should rely on pre-COVID-19 evidence-based principles of anticoagulation management combined with rational approaches to address clinical challenges.[532]
Treatment recommended for ALL patients in selected patient group
Monitor patients closely for signs of clinical deterioration, and respond immediately with appropriate supportive care interventions.[2]
Treatment recommended for ALL patients in selected patient group
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][3][463]
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.[464] 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.[463] There is insufficient evidence to recommend empiric broad-spectrum antimicrobials in the absence of another indication.[3]
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.[463]
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]
Treatment recommended for SOME patients in selected patient group
Primary options
dexamethasone: 6 mg orally/intravenously once daily for 10 days
Secondary options
prednisone: 40 mg/day orally given in 1-2 divided doses for 10 days
OR
methylprednisolone: 32 mg/day orally/intravenously given in 1-2 divided doses for 10 days
OR
hydrocortisone: 160 mg/day orally/intravenously given in 2-4 divided doses for 10 days
Consider low-dose dexamethasone for the management of hospitalized patients with COVID-19 who require oxygen or ventilation. Dexamethasone is associated with reduced mortality risk in patients with severe COVID-19 according to results from the RECOVERY trial in the UK. A total of 2104 patients were randomized to receive low-dose dexamethasone and were compared with 4321 patients randomized to usual care alone. Dexamethasone was found to reduce deaths by one third in patients who were ventilated, and by one fifth in patients who were receiving oxygen only. There were no excess harms identified in using this dose in this patient population. There was no benefit among patients who did not require respiratory support.[536]
As a consequence of this trial, in the UK low-dose dexamethasone is now indicated for the treatment of suspected or confirmed COVID-19 in hospitalized adults receiving oxygen therapy, noninvasive or invasive ventilation, or extracorporeal membrane oxygenation. Oral prednisone or intravenous hydrocortisone is recommended in pregnant or breastfeeding women. Use in children is still being studied.[504]
In the US, the National Institutes of Health guideline panel recommends using dexamethasone in adults with COVID-19 who are mechanically ventilated, and in patients who require supplemental oxygen but who are not mechanically ventilated. The panel recommends against using dexamethasone in patients who do not require supplemental oxygen. It is unknown whether other corticosteroids have the same benefit. However, alternative corticosteroids (e.g., prednisone, methylprednisolone, hydrocortisone) may be used in situations where dexamethasone is not available. Assess whether the patient is suitable for corticosteroid therapy before starting therapy.[3] The Infectious Diseases Society of America supports the use of dexamethasone in hospitalized patients with severe disease.[537]
While the RECOVERY trial found significant benefit with the use of corticosteroids, results from retrospective studies are inconsistent and not strongly supportive of corticosteroid use in COVID-19 despite the signals for some benefits. More studies are necessary to substantiate conclusive benefit.[538]
Monitor patients for adverse effects (e.g., hyperglycemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions. The safety of coadministering dexamethasone and remdesivir is not known.[3]
Treatment recommended for SOME patients in selected patient group
Treat laboratory-confirmed coinfections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][512] 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][503][513][514][515][516][517][518]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
Treatment recommended for SOME patients in selected patient group
Consider experimental therapies such as remdesivir, hydroxychloroquine, lopinavir/ritonavir, and plasma therapy only in the context of a clinical trial or according to local protocols.[2]
The certainty of the evidence for most interventions tested so far is low or very low; however, remdesivir, hydroxychloroquine, and lopinavir/ritonavir might reduce the time to symptom resolution. BMJ: drug treatments for covid-19 – living systematic review and network meta-analysis external link opens in a new window
An expert guideline panel makes a weak recommendation for the use of remdesivir in severe disease, and supports more randomized trials as the quality of the evidence is low. BMJ: remdesivir for severe covid-19 – a clinical practice guideline external link opens in a new window
See the Emerging section for more information.
Treatment recommended for SOME patients in selected patient group
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]
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 under the guidance of a specialist team.[2]
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.[503]
Implement local infection prevention and control procedures when managing patients with COVID-19.
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] 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.[570]
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] The Centers for Disease Control and Prevention (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 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. A symptom-based strategy is preferred in these patients.[520] 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.[511]
Treatment recommended for ALL patients in selected patient group
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.[2]
Airborne precautions are recommended for these interventions (including bubble CPAP) due to uncertainty about the potential for aerosolization.[2]
Patients with hypercapnia, hemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, although emerging data suggest 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]
There is ongoing debate about the optimal mode of respiratory support before mechanical ventilation.[544] NHS England recommends CPAP as the preferred form of noninvasive ventilation. 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.[545] Other guidelines recommend HFNO over noninvasive ventilation, unless HFNO is not available.[3][512] Despite the trend to avoid HFNO, it has been shown to have a similar risk of aerosol generation to standard oxygen masks.[546]
Early CPAP may provide a bridge to invasive mechanical ventilation. Reserve the use of BiPAP for patients with hypercapnic acute or chronic ventilatory failure.[545]
Monitor patients closely for acute deterioration. If patients do not improve after a short trial of these interventions, they require urgent endotracheal intubation.[2][512]
Treatment recommended for ALL patients in selected patient group
Consider endotracheal intubation and mechanical ventilation in patients who are acutely deteriorating despite advanced oxygen/noninvasive ventilatory support measures.[2][3]
Endotracheal intubation should be performed by an experienced provider using airborne precautions.[2] Intubation by video laryngoscopy is recommended if possible.[3] Young children, or adults who are obese or pregnant, may desaturate quickly during intubation and therefore require preoxygenation with 100% fraction of inspired oxygen (FiO₂) for 5 minutes.[2]
Mechanically ventilated patients with acute respiratory distress syndrome (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][3][512] NHS England recommends a low PEEP strategy in patients with normal compliance where recruitment may not be required.[550]
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.[551][552][553][554][555][556] However, this approach has been criticized.[557][558] 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.[559] 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.[551] PEEP should always be carefully titrated.[524]
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][3][512] Longer durations may be feasible in some patients.[560]
Lung recruitment maneuvers are suggested, but staircase recruitment maneuvers are not recommended.[3][512]
Treatment recommended for SOME patients in selected patient group
Consider extracorporeal membrane oxygenation (ECMO) according to availability and expertise if the above methods fail.[2][512][564][565] ECMO is not suitable for all patients, and only those who meet certain inclusion criteria may be considered for ECMO.[566]
There is insufficient evidence to recommend either for or against the routine use of ECMO.[3] Preliminary data on the use of ECMO in patients with COVID-19 is not promising, although it may play a useful role in salvaging select patients.[567][568]
Treatment recommended for SOME patients in selected patient group
The management of sepsis and septic shock in patients with COVID-19 is beyond the scope of this topic. See Complications section.
Treatment recommended for SOME patients in selected patient group
Consider fluid and electrolyte management, antimicrobial treatment, and experimental therapies as appropriate. See Severe COVID-19 section above for more detailed information.
Manage symptoms such as fever, pain, cough, breathlessness, anxiety, agitation, delirium, depression, or insomnia as appropriate. See Severe COVID-19 section above for more detailed information.
Venous thromboembolism prophylaxis is recommended in critically ill patients. Low molecular weight heparin is the preferred option, with unfractionated heparin considered a suitable alternative and preferred over fondaparinux.[533] See Severe COVID-19 section above for more detailed information.
Implement standard interventions to prevent complications associated with critical illness.[2]
Treatment recommended for SOME patients in selected patient group
Primary options
dexamethasone: 6 mg orally/intravenously once daily for 10 days
Secondary options
prednisone: 40 mg/day orally given in 1-2 divided doses for 10 days
OR
methylprednisolone: 32 mg/day orally/intravenously given in 1-2 divided doses for 10 days
OR
hydrocortisone: 160 mg/day orally/intravenously given in 2-4 divided doses for 10 days
Consider low-dose dexamethasone for the management of hospitalized patients with COVID-19 who require oxygen or ventilation. Dexamethasone is associated with reduced mortality risk in patients with severe COVID-19 according to results from the RECOVERY trial in the UK. A total of 2104 patients were randomized to receive low-dose dexamethasone and were compared with 4321 patients randomized to usual care alone. Dexamethasone was found to reduce deaths by one third in patients who were ventilated, and by one fifth in patients who were receiving oxygen only. There were no excess harms identified in using this dose in this patient population. There was no benefit among patients who did not require respiratory support.[536]
As a consequence of this trial, in the UK low-dose dexamethasone is now indicated for the treatment of suspected or confirmed COVID-19 in hospitalized adults receiving oxygen therapy, noninvasive or invasive ventilation, or extracorporeal membrane oxygenation. Oral prednisone or intravenous hydrocortisone is recommended in pregnant or breastfeeding women. Use in children is still being studied.[504]
In the US, the National Institutes of Health guideline panel recommends using dexamethasone in adults with COVID-19 who are mechanically ventilated, and in patients who require supplemental oxygen but who are not mechanically ventilated. The panel recommends against using dexamethasone in patients who do not require supplemental oxygen. It is unknown whether other corticosteroids have the same benefit. However, alternative corticosteroids (e.g., prednisone, methylprednisolone, hydrocortisone) may be used in situations where dexamethasone is not available. Assess whether the patient is suitable for corticosteroid therapy before starting therapy.[3] The Infectious Diseases Society of America supports the use of dexamethasone in hospitalized patients with severe disease.[537]
While the RECOVERY trial found significant benefit with the use of corticosteroids, results from retrospective studies are inconsistent and not strongly supportive of corticosteroid use in COVID-19 despite the signals for some benefits. More studies are necessary to substantiate conclusive benefit.[538]
Surviving Sepsis Campaign guidelines suggest that adults with acute respiratory distress syndrome who are receiving mechanical ventilation and adults with refractory shock should receive corticosteroids, although this recommendation is based on weak evidence.[512]
Monitor patients for adverse effects (e.g., hyperglycemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions. The safety of coadministering dexamethasone and remdesivir is not known.[3]
Treatment recommended for SOME patients in selected patient group
Consider experimental therapies such as remdesivir, hydroxychloroquine, lopinavir/ritonavir, and plasma therapy only in the context of a clinical trial or according to local protocols.[2]
The certainty of the evidence for most interventions tested so far is low or very low; however, remdesivir, hydroxychloroquine, and lopinavir/ritonavir might reduce the time to symptom resolution. BMJ: drug treatments for covid-19 – living systematic review and network meta-analysis external link opens in a new window
An expert guideline panel makes a weak recommendation for the use of remdesivir in severe disease, and supports more randomized trials as the quality of the evidence is low. BMJ: remdesivir for severe covid-19 – a clinical practice guideline external link opens in a new window
See the Emerging section for more information.
Treatment recommended for SOME patients in selected patient group
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]
Treatment recommended for SOME patients in selected patient group
Palliative care interventions should be made accessible at each institution that provides care for patients with COVID-19. Identify whether the patient has an advance care plan and respect the patient’s priorities and preferences when formulating the patient’s care plan.[2] Follow local palliative care guidelines.
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