Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can experience a range of clinical manifestations, from no symptoms to critical illness and death. Currently, no Food and Drug Administration (FDA)-approved drugs exist for the treatment of COVID-19.1
Mild illness – Patients with mild illness may present with signs and symptoms of COVID-19, such as fever, cough, muscle pain, and sore throat, but may not exhibit shortness of breath or abnormal imaging results. Most patients with mild illness can be managed through telemedicine or in the ambulatory setting. Any patient with risk factors for severe disease should be monitored closely because the clinical course of the disease may progress rapidly in some patients.1-3
Moderate illness – Moderately ill patients have evidence of lower respiratory disease with SpO2 >93% on room air. These patients should be admitted to a healthcare facility for close observation, given the risk of rapid disease progression. Initial evaluation should include chest imaging by x-ray, ultrasound, or computed tomography (CT). Complete blood count (CBC) with differentials and a metabolic profile, including liver and renal function tests, should be performed. Measurements of inflammatory markers, such as C-reactive protein (CRP), D-dimer, and ferritin, may have prognostic value. Administer empiric antibiotics for community-acquired pneumonia if bacterial pneumonia or sepsis is strongly suspected.1
Severe illness – Severely ill patients have SpO2 ≤93% on room air at sea level, respiratory rate >30/min, PaO2/FiO2 <300 mm Hg, and/or lung infiltrates >50%. Oxygen therapy should be initiated immediately using nasal cannula or high-flow oxygen. Evaluation should include chest imaging, CBC, and a metabolic panel. Measurements of inflammatory markers may have prognostic value. Administer empiric antibiotics if bacterial pneumonia or sepsis is suspected. These patients may experience rapid disease progression and will likely need to undergo aerosol-generating procedures. These patients should be placed in airborne infection isolation rooms (AIIRS).1
Critical illness – Critically ill patients may have acute respiratory distress syndrome (ARDS), virus-induced distributive shock, cardiac dysfunction, cytokine storm from elevations in inflammatory cytokines, multiorgan dysfunction, and/or exacerbations in underlying comorbidities. Critical care management of COVID-19 patients should not differ substantially from the management of other critically ill patients, with the exception of special precautions to limit the spread of the virus.1
Management of Acute Respiratory Distress Syndrome from COVID-19
The leading cause of mortality with COVID-19 is respiratory failure from ARDS; without an effective therapy, current management of this viral infection is supportive.4 A trial of high-flow nasal oxygen should be considered in patients with moderately severe hypoxemia. This procedure provides high concentrations of humidified oxygen, low levels of positive end-expiratory pressure, and can facilitate the elimination of carbon dioxide, potentially avoiding the need for intubation or mechanical ventilation. Patients should be closely monitored for clinical deterioration to reduce the need of emergent intubations that may increase the risk of infection to healthcare workers.5
Prone positioning should be applied early, given its association with reduced mortality in other causes of severe ARDS. Veno-venous extracorporeal membrane oxygenation (ECMO) is reserved for the most severe cases of ARDS. In one report, out of 28 patients who received ECMO, 14 died, 9 were still on ECMO, and only 5 were successfully weaned.6 Additional therapeutic options for the management of severe ARDS in patients with COVID-19 are summarized in the table below.
- National Institutes of Health (NIH). Management of Persons with COVID-19. Available at https://covid19treatmentguidelines.nih.gov/overview/management-of-covid-19/.
- Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708-1720.
- Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 2020;395:497-506.
- Ruan Q, Yang K, Wang W, et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;3:1-3.
- Matthay MA, Aldrich JM, Gotts JE. Treatment for severe acute respiratory distress syndrome from COVID-19. Lancet Respir Med. 2020;March 20: Epub ahead of print.
- Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020;8:506-517.
- Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.
N Engl J Med. 2018;378:1965-1975.
- Alhazzani W, Moller 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;46:854-887.