Management of COVID-19

Mild disease

Definition of disease severity

No symptoms OR mild upper respiratory tract symptoms OR new cough, myalgia, aesthenia without shortness of breath or reduction in oxygen saturation

Supportive care

Antipyretics if required

Medications

Sotrovimab

• Do NOT use in fully vaccinated patients unless immunosuppressed
• Consider within 5 days of onset of symptoms in adults who do NOT require oxygen therapy and have one or more risk factors for disease progression:
  • Diabetes (requiring medications)
  • Obesity
  • CKD (eGFR <60)
  • NYHA II or higher CCF
  • COAD
  • Moderate to severe asthma
  • Age 55 or older
• May reduce risk of hospitalisation
• Requires single one hour infusion of 500mg sotrovimab
• Predominantly beneficial in those unvaccinated or partially vaccinated and patients who are immunosuppressed irrespective of vaccination status

Budesonide

• Consider inhaled budesonide 800mcg BD in symptomatic adults who do NOT require oxygen and have one or more risk factors for disease progression

REGEN-COV (Casirivimab/Imedvimiab)

• Consider use in mild outpatients who have one or more risk factors for disease progression within 7 days of onset

Steroids

• Do NOT use systemic steroid therapies

Children, adolescents, older frail patients and pregnant/breastfeeding women should not receive disease-modifying treatments in mild disease unless as part of a trial

Moderate to severe disease

Definition of disease severity

Moderate

• Stable adult patients with respiratory and/or systemic symptoms or signs
• SpO2 >92% (or >90% with chronic lung disease) with up to 4L/min oxygen via nasal prongs
• Fatigue, fever or persistent cough
• Clinical or radiological signs of lung involvement
• No severe criteria met

Severe illness

• Adult patients with any of the following:
  • RR >= 30
  • SpO2 <92% at rest
  • P/F <= 300

Medications

Steroids

• Dexamethasone 6mg daily IV or PO for up to 10 days if receiving oxygen

Remdesivir

• Consider use for patients requiring oxygen but not ventilation
• Can continue if started before ventilation required

Sotrovimab

• Consider use within 5 days of symptom onset in adults who do not require oxygen and have one or more risk factors for progression
• Consider use for those unvaccinated, partially vaccinated or immunosuppressed
• Do NOT routinely use in fully vaccinated patients unless immunosuppressed

REGEN-COV (Casirivimab/Imdevimab)

• Consider use in seronegative patients with moderate to severe COVID

Baricitinib

• Consider for hospitalised patients requiring supplemental oxygen, HFNP or NIV

Sarilumab

• Consider in adults requiring HFNP, NIV or invasive ventilation

Tocilizumab

• Consider for patients requiring supplemental oxygen, particularly where there is evidence of systemic inflammation

Fluid management

Restrictive fluid regime is recommended for all moderate to severe disease patients, avoiding the use of ‘maintenance fluids’, high volume enteral nutrition or fluid boluses for hypotension

Discharge planning

Must stay in home isolation until:

• at least 14 days have passed since onset of symptoms AND
• Resolution of fever and respiratory symptoms for last 72 hours
  • If incomplete resolution of symptoms, there must be substantial improvement, absence of fever for 72 hours and two consecutive negative PCR taken over at least hours

Severe to critical disease

Definition of disease severity

Severe illness

• Adult patients with any of the following:
  • RR >30
  • SpO2 <92%
  • P/F <=300

Critical illness

• Adult patients with any of the following:
  • P/F <200, respiratory distress or ARDS. Includes patients deteriorating despite NIV/HFNP or requiring mechanical ventilation
  • Hypotension or shock
  • Impairment of consciousness
  • Other organ failure

Day 5-10 is the most at risk period

Medications

Dexamethasone 6mg IV or PO daily for up to 10 days

Remdesivir if requiring oxygen but NOT ventilation (can continue if started already)

REGEN-COV (Casirivimab/Imdevimab) in seronegative patients

Baricitinib if requiring oxygen, especially if signs of systemic inflammation

Sarilumab in adults requiring HFNP, NIV or invasive ventilation

Tocilizumab if requiring oxygen, particularly with evidence of systemic inflammation

Fluid regime

Restrictive fluid regime

Shock treatment

Avoid synthetic colloids for shock

Noradrenaline as first-line vasopressor

Other

Request an influenza test and consider oseltamivir 75mg BD until test proves negative

Respiratory support

Target SpO2 92-96% (or 88-92% if at risk of hypercapnoea)

NIV and HFNP should ideally only be used in negative pressure rooms > single rooms > cohort shared spaces

CPAP if first-line support for patients with persistent hypoxaemia (FiO2 >0.4)

Most patients require 10-12cmH20 of pressure support

If CPAP is not tolerated or unavailable, consider HFNP as an alternative

Videolaryngoscopy should be the first-line method of intubation

Lung protective ventilation is paramount – Vt 4-8mL/kg of predicted body weight, PPlat <30

PEEP 10-15 preferred over lower PEEP in moderate to severe ARDS

Consider prone positioning for any patient requiring supplemental oxygen and hospital admission

• Target 3 hours per day minimum (>8 is ideal)
• This should not delay intubation or NIV use if deteriorating
• If mechanically ventilated, target >12 hours per day of proning

Consider recruitment manoeuvres if hypoxaemic despite optimised ventilation and proning (while avoiding stepwise or staircase methods)

Inhaled pulmonary vasodilators should only be used as a rescue therapy

ECMO remains a rescue option with specific selection criteria

Last Updated on December 29, 2021 by Andrew Crofton