Management Strategies

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.

References

  1. National Institutes of Health (NIH). Management of Persons with COVID-19. Available at https://covid19treatmentguidelines.nih.gov/overview/management-of-covid-19/.
  2. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708-1720.
  3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 2020;395:497-506.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.

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Patient Toolkit

The COVID FRONTLINE Patient Toolkit is a resource center for patients who have been diagnosed with or who are interested in learning about COVID-19. Choose from the options below to learn more.

Clinical Toolkit

The COVID-19 Clinical Toolkit is an online tool that aims to provide clinicians with up-to-date information on the presentation, prognosis, pathophysiology, and treatment strategies for COVID-19. Click on one of the options below to learn more.

This activity is provided by Med Learning Group. This activity is co-provided by Ultimate Medical Academy/CCM.
This activity is supported by educational grants from AbbVie, Astellas, Genentech, Merck & Co., Inc., and Pfizer.

Copyright © 2019 | COVID Frontline | All Rights Reserved | Website by Divigner

Updates in the Treatment and Prevention of COVID-19​

Emergency use authorization for casirivimab/imdevimab in patients with mild-to-moderate COVID-19

The combination of the monoclonal antibodies casirivimab and imdevimab (previously known as REGN-COV2) has been authorized for emergency use for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients (≥12 years of age and ≥40 kg) who are at high risk for progressing to severe COVID-19 or hospitalization.1

Interim results from 275 nonhospitalized patients in a placebo-controlled trial of casirivimab plus imdevimab found that the combination therapy reduced viral load, with a greater effect in patients whose immune response had not yet been initiated or who had a high viral load at baseline. Patients who received casirivimab/imdevimab required fewer medical visits for COVID-19 than patients who received placebo (3% vs 6%, respectively). Among patients who were serum antibody-negative at baseline, 15% in the placebo group and 6% in the treatment group required COVID-19-related medical care.2 

Baricitinib in combination with remdesivir authorized for emergency use in hospitalized patients

Baricitinib, in combination with remdesivir, is authorized for emergency use in adult and pediatric patients ≥2 years of age hospitalized for COVID-19 who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).3

A recent trial of 1033 patients hospitalized for COVID-19 found that baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time (7 days vs 8 days, respectively; P= .03). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination therapy and 18 days with the control (rate ratio for recovery, 1.51). The addition of baricitinib to remdesivir was associated with 30% higher odds of improvement in clinical status at day 15 compared with remdesivir alone.4 

 

References 

  1. Emergency use authorization (EUA) of casirivimab and imdevimab. Available at fda.gov/media/143892/download Accessed 12/23/2020.
  2. Weinreich DM, Sivapalasingam S, Norton T, et al. REGN-COV2, a neutralizing antibody cocktail, in outpatients with Covid-19. N Engl J Med. 2020;Dec 17:Epub ahead of print. Available at nejm.org/doi/full/10.1056/NEJMoa2035002Accessed 12/23/2020.
  3. Emergency use authorization (EUA) of baricitinib. Available at fda.gov/media/143823/download Accessed 12/23/2020.
  4. Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with Covid-19. N Engl J Med. 2020;Dec 11:Epub ahead of print. Available at nejm.org/doi/full/10.1056/NEJMoa2031994 Accessed 12/23/2020.