Difference between revisions of "COVID-19"

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*** 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients  
 
*** 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients  
 
* Limited data on [[Ritonavir]], [[chloroquine]], and hydroxychloroquine
 
* Limited data on [[Ritonavir]], [[chloroquine]], and hydroxychloroquine
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*Convalescent plasma (plasma/antibodies from healthy survivors)
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**Has been used in prior viral epidemics with success
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**No proven benefit, but actively being researched
  
 
===Contraindicated===
 
===Contraindicated===
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** WHO cautiously states that high flow [[oxygen]] may be occasionally indicated.
 
** WHO cautiously states that high flow [[oxygen]] may be occasionally indicated.
 
*There is anecdotal concern about [[NSAID]] use; some have suggested preferentially using [[acetaminophen]] however, there are no formal recommendations to avoid NSAIDs at this time
 
*There is anecdotal concern about [[NSAID]] use; some have suggested preferentially using [[acetaminophen]] however, there are no formal recommendations to avoid NSAIDs at this time
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*There is anecdotal concern about ACEi/ARB use, however no formal recommendations to avoid use at this time
  
 
==Special Situations==
 
==Special Situations==
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* May consider discontinuation of hospital isolation when:
 
* May consider discontinuation of hospital isolation when:
 
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
 
** Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing
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 +
===Legal Considerations===
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*HIPPA: in USA relaxation of HIPPA rules for telehealth
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**“HHS…will waive potential HIPAA penalties for good faith use of telehealth during the nationwide public health emergency due to COVID-19.”
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***This includes “non-public facing” products including Facetime/Skype:
 +
****www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html
  
 
==Prognosis==
 
==Prognosis==

Revision as of 00:13, 27 March 2020

See also prevention of COVID-19 transmission in the healthcare setting; COVID-19 (peds); and COVID-19 in pregnancy.

Background

  • The current national and international pandemic is from a virus named SARS-CoV-2 (previously 2019-nCoV), which causes a disease named COVID-19 (also known as "2019 Novel Coronavirus")
  • First detected in Wuhan, China

Specific Coronavirus Sub-Types of Clinical Importance

Virology

  • Coronaviruses are common human pathogens
    • Cause the common cold
    • In epidemics, cause up to one-third of community-acquired upper respiratory tract infections in adults; and may cause diarrhea in infants and children
  • SARS-CoV-2 is a novel coronavirus (a new strain not previously identified in humans)
    • Likely primary source = bats
    • It is a betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus. Middle East respiratory syndrome (MERS) virus is another, more distantly related, betacoronavirus. Like the SARS coronavirus, SARS-CoV-2 uses angiotensin-converting enzyme 2 [ACE2] for cell entry
  • Surface survival time of SARS-CoV-2:
    • stainless steel: persists for 3 hours (or longer)
    • underscores the importance of environmental cleaning / disinfection
      • cleaning gets rid of the proteins that would interfere with a disinfectants effectiveness
    • Note: studied in a simulated lab environment. Lab virions not covered in protein and mucus and other things that would mimic real life and that could prolong survival

Epidemiology

Ro Example
  • Expected patient outcomes (from data so far):
    • 80% have mild symptoms
    • 15% have severe disease requiring hospitalisation
    • 5% require mechanical ventilation
  • COVID-19: R0 = 2.2 - 4.2
    • Where R0 = expected number of secondary cases produced by a single typical infection in a susceptible population (basic reproductive rate)
    • R0 for seasonal flu ~ 1.3
    • R0 for pandemic flu ~ 1.5-1.8
  • Incubation: 5 days (median); range of 2-14 days
  • Serial interval duration = 7.5 days
    • Serial interval refers to the time from illness onset in successive cases in a transmission chain

Risk Factors for Severe Disease

  • Older age
  • Underlying conditions (lung disease, heart disease, diabetes)


NOT Risk Factors

Clinical Features

Initial Presentation

  • Many patients are asymptomatic
  • At onset of symptoms: fever, dry cough, myalgias, fatigue, shortness of breath
    • Fever and cough start early, shortness of breath noted about 9 days into illness
    • Fever not present in all adults (less common in vulnerable populations)
    • Less common: cough with sputum, sore throat, headache, congestion, GI symptoms, anosmia
Symptom[1] %
Fever 87.9
Dry cough 67.7
Fatigue 38.1
Sputum production 33.4
Shortness of breath 18.6
Myalgia or arthralgia 14.8
Sore throat 13.9
Headache 13.6
Chills 11.4
Nausea or vomiting 5.0
Nasal congestion 4.8
Diarrhea 3.7
Hemoptysis 0.9
Conjunctivitis 0.8

Common Complications

  • Most common complications: pneumonia, ARDS (average 8 days from onset, 20% of patients in China)
  • According to limited ICU data (21 cases) from Washington state (Arentz et al):
    • Vasodilatory shock reported in 67% of ICU admissions
    • Cardiomyopathy reported in 33% of ICU admissions
    • Mortality reported 67% of ICU admissions

Differential Diagnosis

Influenza-Like Illness

Causes of Pneumonia

Bacteria

Viral

Fungal

Parasitic

Evaluation

Workup

Viral Testing Background (Real-Time PCR)

  • Internationally the WHO has distributed kits[2]
  • In the United States, the US Centers for Disease Control (CDC) is distributing testing to public health labs[3]
  • BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype

Who to Test (Persons Under Investigation)

  • Patients should be carefully evaluated to determine if they meet Persons Under Investigation (PUI) criteria
  • Due to a lack of available tests, non-PUI patients (including the worried well) should not have testing performed
  • Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g. influenza, RSV)
    • In many systems, testing algorithms assume patients do not have COVID-19 if influenza or RSV positive
CDC PUI Guidance[4]

Your local PUI testing guidelines may be different, depending on test availability and local epidemiology; see state or local health departments and internal hospital resources

  • "Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested."
  • Priorities for testing include:
    1. Hospitalized patients who have signs and symptoms compatible with COVID-19^ (in order to inform decisions related to infection control)
    2. Other symptomatic individuals with risk factors for severe disease
      • Older adults
      • Individuals with chronic medical conditions and/or an immunocompromised state (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease)
    3. Symptomatic persons who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient
      • Including healthcare personnel
      • INcluding history of travel from affected geographic areas

^Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).

Clinical Sample Collection[5]

Testing can be done in ambulatory setting if absolutely needed (see precautions)

  1. Upper respiratory tract specimen
    • Nasopharyngeal (NP) swab
      • Some systems allow sending both flu/RSV and COVID-19 test on the same swab to conserve testing supplies
  2. Additionally include lower tract specimen, if available
    • CDC does NOT recommend inducing sputum (because aerosol generating)
    • For productive cough patients: collect sputum
    • For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation): collect lower respiratory tract aspirate or bronchoalveolar lavage sample
    • May include in same testing tube as upper respiratory track specimen (i.e. send as a single test) in some systems

Diagnostic Findings

COVID one pager with links.jpg
COVID one pager with links 2.jpg
Covidcxr.jpg

Labs

  • Note that BIOFIRE Respiratory Panel Corona Virus assay does NOT detect this COVID-19 subtype
  • Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
    • Elevated d-dimer and severe lymphopenia are associated with increased mortality
    • RT-PCR is currently test of choice for confirming cases
      • Test kit availability is currently limited as of mid March
      • Consider viral respiratory panel to identify alternative diagnoses though co-infection has been reported as high as 7-20%

X-ray

    • Portable CXR preferred in PUI to prevent spread of infection
    • May be normal in early disease
    • Typical pattern is peripheral patchy ground glass opacities (GGO)
    • More opacities correlates with worse disease
    • GGOs may coalesce and appear as infiltrates

CT

  • Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
    • CT (86%) more sensitive than CXR (59%) for detecting GGOs
    • From the American College of Radiology (3/11/20): “Generally, the findings on chest imaging in COVID-19 are not specific, and overlap with other infections, including influenza, H1N1, SARS and MERS. Being in the midst of the current flu season with a much higher prevalence of influenza in the U.S. than COVID-19, further limits the specificity of CT.”

US

  • Uncertain role in diagnosis at this time
    • May reveal B lines, consolidation, or "ragged" appearance of pleural line

Management

See prevention of COVID-19 transmission in the healthcare setting for PPE recommendations

COVID-19 PPE Summary Table

Example summary flow chart for determining PPE use














Contact Category Precations Room Type
General (all persons) Social distancing; meticulous hygiene NA
Undifferentiated patients at risk (e.g. prior to evaluation or testing) Contact and droplet precautions including eye protection Negative-pressure NOT required
Persons Under Investigation Contact and droplet precautions including eye protection Negative-pressure NOT required
Aerosol-Generating Procedures Contact and airborn precautions including eye protection Negative-pressure required

Mild Cases

  • Supportive care is mainstay of therapy for patients with mild viral symptoms
  • Most patients will do well enough for discharge home
  • Discuss with Dept of Public Health, who will guide testing and, if discharging, help patient remain in isolation at home

Respiratory failure

  • NIPPV may increase the spread of viral particles via droplets, making early intubation the preferred airway management strategy in patients with respiratory distress/failure
    • Using 2 viral filters attached to a "2-tube NIPPV circuit" in a negative pressure room may sufficiently prevent viral spread

Intubation of Potential COVID-19 Patients

Aerosol-generating procedure: see this link for PPE recommendations and related precautions

  • Use checklist if available (see example: File:Harbor COVID Airway Management v3-16-20.pdf)
  • Consider use of an Aerolsol Box (Plexiglas box that goes around patient head), if available
  • Use BVM with viral filter or avoid BVM altogether, if possible
  • Use RSI to prevent coughing gagging; consider higher dosing of paralytics.
  • Most experienced provider should perform intubation
  • Upper airway edema may be present leading to difficult intubations
  • Use video laryngoscopy to keep provider face further away from patient (afterwards, clean with grey wipes, observe 3 min wet time)

Lung Protective Mechanical Ventilation

Lung Protective Ventilator Settings[6] should be the default for all intubated patients. It has demonstrated mortality benefit for ARDS-like pulmonary conditions; limits barotrauma and decreases complications of high FiO2[7][8]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[9]
      • Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
    • Titrate down if peak pressure >30 mmHg
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. Respiratory Rate (titrate for ventilation)
    • Average patient on ventilator requires 120mL/kg/min for eucapnia
    • Start 16-18 breaths/min
    • Maintain pH = 7.30-7.45
  5. FiO2/PEEP (titrate for oxygenation)
    • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80

Investigational Agents

Generally not started in ED setting; CDC does not recommend for or against any investigational therapies at this time

  • Remdesivir (IV)
    • Consider for severely hypoxemic (Mechanical vent, high PEEP, FiO2 requirements >40%,).
    • Contact Gilead directly for use: compassionateaccess@gilead.com
    • Background: novel antiviral nucleotide analog. Initially developed for Ebola and Marburg (has since been found to show activity against other single stranded RNA viruses such as RSV, Lassa fever virus, Nipah virus and the coronaviruses including MERS and SARS)
      • 3 clinical trials across country (one is NIH adaptive trial)
      • 2 other trials are investigational open-label trials testing different dosages for moderate or severely hospitalized patients
  • Limited data on Ritonavir, chloroquine, and hydroxychloroquine
  • Convalescent plasma (plasma/antibodies from healthy survivors)
    • Has been used in prior viral epidemics with success
    • No proven benefit, but actively being researched

Contraindicated

  • Avoid steroids unless strong non-COVID indication (due to progression of viral replication reported from prior coronaviruses; e.g. MERS, SARS)
  • Avoid nebulizers as they are generally ineffective and may aerosolize virus
    • Albuterol with spacer is safer, though probably ineffective unless co-occuring reactive airway disease
      • MDI equivalents: Albuterol or ipratropium
        • <20 kg or 5yrs old: 4-5 puffs with a spacer every 20 minutes. 4 breaths between puffs.
        • >20 kg or 5yrs old: 8-10 puffs with a spacer every 20 minutes. 4 breaths between puffs.
  • Generally avoid BiPAP and high-flow nasal oxygen as these may increase viral spread
    • WHO cautiously states that high flow oxygen may be occasionally indicated.
  • There is anecdotal concern about NSAID use; some have suggested preferentially using acetaminophen however, there are no formal recommendations to avoid NSAIDs at this time
  • There is anecdotal concern about ACEi/ARB use, however no formal recommendations to avoid use at this time

Special Situations

Covid-19 and STEMI

  • Administer Retavase (reteplase) as a bolus followed by a second bolus at 30 minute rather than PCI.
  • Dosing: 10u Retavase (reteplase) IV bolus

Disposition

  • Mild cases for persons under investigation for Covid-19 awaiting a positive test result can self quarantine at home in conjunction with the local Public Health Dept
    • Note: symptoms may worsen over 2nd week of illness

Admission

  • Hospitalize: Respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care
    • PSI/PORT, MuLBSTA, and CURB65 scores have all been proposed criteria for admission and predicting outcomes.
  • May consider discontinuation of hospital isolation when:
    • Resolution of fever without anti-pyretic, resolution of symptoms, and negative COVID19 testing

Legal Considerations

  • HIPPA: in USA relaxation of HIPPA rules for telehealth
    • “HHS…will waive potential HIPAA penalties for good faith use of telehealth during the nationwide public health emergency due to COVID-19.”
      • This includes “non-public facing” products including Facetime/Skype:
        • www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

Prognosis

All-Comers

  • Case fatality rate (CFR) = 2-4% (from Hubei data)
    • SARS ~ 10%
    • MERS ~ 35%
    • Seasonal flu ~ 0.1-0.2%
    • 1918 Pandemic Influenza ~ 2-3%

Relation to Age

Case fatality rates by country, age, and percent (%)
Age 80+ 70–79 60–69 50–59 40–49 30–39 20–29 10–19 0–9
China as of 11 February[10] 14.8 8.0 3.6 1.3 0.4 0.2 0.2 0.2 0.0
Italy as of 16 March[11] 19.2 11.8 3.2 1.0 0.3 0.2 0.0 0.0 0.0
South Korea as of 21 March[12] 10.24 6.28 1.52 0.42 0.08 0.11 0.0 0.0 0.0

See Also

COVID-19 Pages

External Links

Video

References

  1. World Health Organization. "Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)" (PDF): 11–12. Retrieved 5 March 2020.
  2. Sheridan, Cormac . "Coronavirus and the race to distribute reliable diagnostics". Nature Biotechnology https://www.nature.com/articles/d41587-020-00002-2
  3. https://www.internationalreagentresource.org/
  4. Criteria to Guide Evaluation and Laboratory Testing for COVID-19. Updated March 20, 2020. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
  5. Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19). March 19, 2020 Revision. https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html
  6. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  7. ARDSnet
  8. O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  9. Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.
  10. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team (17 February 2020). "The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020". China CDC Weekly. 2 (8): 113–122. Retrieved 18 March 2020.
  11. Epidemia COVID-19. Aggiornamento nazionale 16 marzo 2020" (PDF) (in Italian). Rome: Istituto Superiore di Sanità. 16 March 2020. Retrieved 18 March 2020.
  12. "코로나바이러스감염증-19 국내 발생 현황 (3월 21일, 정례브리핑)". Korea Centers for Disease Control and Prevention. 21 March 2020. Retrieved 21 March 2020.