Last month’s roundup presented some of the early research on COVID-19. This month’s roundup will focus on emerging guidance on the treatment and management of people presenting to hospital with suspected severe COVID-19 infection. The acutely ill commonly present with high respiratory rate, low oxygen saturations, low blood pressure, tachycardia and pyrexia.
Initial emergency treatment is aimed at reversing hypoxia, restoring haemodynamic stability, and treating the underlying cause, whilst providing ongoing assessment using a track and trigger system, for example NEWS2. In this roundup, recent guidance published by the World Health Organisation (WHO, 2020), British Medical Journal (BMJ, 2020), on themanagement of the acutely ill person with suspected or confirmed COVID-19 will be reviewed, as well as specific treatment guidelines by the British Thoracic Society (BTS, 2017) and National Institute for Health and Care Excellence (NICE, 2014).
Management of respiratory instability
Low oxygen saturations and high respiratory rate requires early intervention with appropriate oxygen therapy, taking into account underlying comorbidities. BMJ guidance (2020) and WHO (2020) recommends giving supplemental oxygen and to titrate fl ow COVID-19: Emerging guidance and treatment rates to reach a target of SpO2 ≥94%.
NHS England and NHS Improvement (2020) have produced supplemental guidance for the management of patients presenting with suspected COVID-19 and recommend British Thoracic Society guidance on the use of supplemental oxygen (BTS, 2017). The guidelines recommend that when the patient is in a critical condition and is persistently breathless (respiratory rate >20) or has oxygensaturation of less than 94%, with no underlying respiratory disease, a face mask with a reservoir bag should be used to deliver oxygen at a rate 10–15 L/minute (60–100%).
When oxygen therapy is indicated, it should be prescribed according to local prescribing guidance. If the patient continues to deteriorate, admission to ICU should be considered. NICE guidance (2020) recommends admission to critical care should take into account frailty score, likelihood of recovery to a level acceptable to the patient, and the patient’s past and present wishes.
Management of cardiovascular instability with fluid resuscitation
To maintain blood pressure and heart rate within normal limits, intravenous crystalloid is recommended (0.9%sodium chloride or plasma-lyte 148). BMJ (2020) guidance recommends conservative fl uid management in adults and children with severe COVID-19 infection when there is no evidence of shock, as aggressive fl uid resuscitation may worsen oxygenation. Type, amount and duration of fl uid management will be according to local protocols, but an initial bolus of 500 mls over 15–30 minutes may be suffi cient to restore blood pressure and heart rate to within normal limits.
There is ongoing debate on whether crystalloid is superior to colloid, and a recent Cochrane review has systematically reviewed evidence comparing the use of colloids versus crystalloids in critically ill patients (Lewis et al, 2018). This review reported no difference in outcomes when the two interventions were compared but as a result of gaps in the evidence base, crystalloid was still recommended as fi rstline treatment.
Pharmacological treatment: antipyretics
WHO (2020) guidelines recommend an antipyretic/analgesic, for example paracetamol, for the relief of fever and pain. Antipyretics may increase patient comfort, but fever is a normal physiological response to infection and some guidelines do not routinely recommend prescribing in acute respiratory illness (Centre for Evidence-based Medicine, 2020).When using other antipyretics, such as non-steroidal anti-infl ammatory drugs (NSAIDs), anecdotal evidence has reported adverse events in people with COVID-19 who have taken NSAIDs (Day, 2020).
A recent editorial in the BMJ proposes that they should not be used as fi rstline treatment for COVID-19 symptoms, including pyrexia (Little, 2020). Therefore, paracetamol is recommended if an antipyretic or analgesic is prescribed for mild to moderate pain.
COVID-19 is a viral infection and antibiotics may not be indicated. However, if the patient is pyrexial, blood and sputum cultures must be obtained and antibiotics prescribed. Guidance published by NICE (2014) on management of community-acquired pneumonia recommend antibiotics based on illness severity and local antimicrobial guidance. Many health authorities in the UK have specifi c guidance that is available through the Microguide application (2020), which can be downloaded onto any smart phone or mobile device.
Corticosteroids are routinely prescribed during acute exacerbations of some respiratory conditions, such as exacerbation of asthma or chronic obstructive pulmonary disease. However, in COVID-19, they are not recommended (WHO, 2020) because although they reduce infl ammation, they also suppress the immune response and may delay clearance of the infective pathogen. Evidence to support this recommendation was published in the Lancet (Russell et al, 2020) where patients with similar conditions, for example, Middle Eastern Respiratory Syndrome, Severe Adult Respiratory Syndrome and infl uenza were reported.
In the studies reviewed, increased mortality, length of stay and long-term complications (such as osteoporosis) were reported in patients receiving steroid treatment. Whilst there were some methodological limitations in the reported studies, and the studies
were not directly reporting results from people with COVID-19, the authors deemed the evidence suffi ciently conclusive to recommend avoiding steroids in this group.
Clinical trials and COVID-19
Treatment options for people presenting with severe COVID-19 are limited and, with the goal of fi nding new treatments, one of the largest randomised controlled trials in the world is underway, in the UK. The Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial is testing the effect of standard care against standard care plus antivirals (lopinavir-Ritonavir), steroids (dexamethasone), anti-malarials (hydroxychloroquine) or antibiotics (azithromycin). Outcome measures are mortality, discharge, need for ventilation and need for renal replacement therapy at 28 days. Over 130 hospitals in the UK are participating and it is hoped that results may provide evidence for future treatment of acute presentations.
Adopting a person-centered and systematic approach to the management of the acutely ill person presenting with COVID-19 will improve quality of care and may impact on survival rates. Oxygen therapy, fl uid resuscitation and, where indicated, antibiotic treatment are the cornerstones of prescribing in this population. International large-scale prospective research will contribute to establishing effective treatments in the future but, in the meantime, early detection, close monitoring, treatment escalation and patient-centred decision-making is paramount.
Author : Ruth Paterson