COVID-19 Management

- Updates
Second Wave Insights
• Virus does not kill directly. It kills by immune activation and inflammation
• Observation and escalation of treatment is recommended
• Steroids in early replicative phase can be detrimental
• Severe disease and death can occur even in the absence of comorbidities
• The CT lesions are far more diffuse than in the first peak
• Surface transmission is unlikely and possible air transmission is proposed
strongly
• Clinical features, inflammatory markers and CT chest should be used to
diagnose cases where clinical suspicion is high and RT PCR is negative.
Initial evaluation in a SARI case
• Review comorbidities
• Risk factor for severe disease include – Age >60 yrs, CAD, CVA, heart failure,
CKD, chronic respiratory diseases, uncontrolled DM, SHTN, DCLD, morbid
obesity, on immunosuppressive therapy currently
• Assessment of vitals
• Need for critical care if RR >30, unable to speak full sentences, cyanosis or
SpO2 < 85% in room air, SBP <90mmHg despite fluid resuscitation, agitated,
confused, qSOFA score of 2 or more
• Classify patients clinically
Investigations
Some pearls regarding
investigations..
• CRP can be used as a guide for steroid use. However, also look for
WBC counts, cultures and procalcitonin wherein if there is a bacterial
infection you may have to taper steroids and start on appropriate
antibiotics
• IL 6 results can be erroneous due to lack of lab standardization,
transport delays and temperature exposure
• D-dimer is an important marker and serial values every 2-3 days are
recommended
• Procalcitonin remains normal in uncomplicated COVID-19 and
elevations must be investigated to rule out secondary infections
CT chest in COVID-19
• In patients having comorbidities and minimal respiratory symptoms
CT may be delayed till the end of first week of symptom onset
• In patients with moderate or severe disease needs to be done at the
earliest
• High suspicion cases with negative RT PCR should be correlated
clinically
Management
• Mild disease: Home isolation
• Identify – no evidence of hypoxia, RR <24/min, CTSS <8/25
• Manage
• Isolation and all COVID appropriate behavior
• Monitoring: SpO2 three to four times a day, temperature, 6 minute walk test
• Less than 94% in three successive readings
• Temperature more than 100 degree F in spite of paracetamol for five or more days
• Pulse rate more than 100 or respiratory rate more than 20 for five or more days
• 6 MWT – drop in saturation of more than 3-5%
• Red flag signs – high grade fever, severe cough, disoriented, SOB, slurred speech,
drowsiness
• Treatment for home isolation
• Rehydration
• Paracetamol 650mg every 4-6 hrs not more than four times in 24 hrs
• Nutritional support
• No role for Azithromycin/ Doxycycline/ HCQs/ Ivermectin/ Favipravir
• Steroids must NOT be used in patients with mild disease
• Budesonide inhalation 800mcg BD for 5-7 days can be given
• Advisable to start T. Aspirin 75mg OD in high risk individuals
• Other advices include sequential change of posture, continue taking medicines for
previous comorbidities, have proper sleep, talk with family and friends.
Proning
• Moderate disease
• Identify – RR >24/min, SpO2 90-94%, CTSS 8-15/25
• Manage
• Admit in wards
• Oxygen support
• Target saturation 92-96% preferably with face mask
• Awake proning to be recommended
• Lab and clinical monitoring as advised previously
• Treatment of moderate disease
• Antiviral therapy
• Remdesivir – most guidelines have removed it
• Start early preferably within first 5-7 days of symptom onset
• Reduces only days of hospitalization
• Convalescent plasma – not recommended
• Anti inflammatory therapy – Inj dexamethasone 6mg IV od for 5-10 days
• Anticoagulation – Inj enoxaparin 1mg/kg OD. In ESRD, UFH – 5000U SC BD
• Watch for cytokine storm – day 7/8, unremitting fever, cytopenia, hyperferritinemia
Some pearls regarding steroid use..
• Steroids should strictly be avoided in
• Asymptomatic
• Mild symptoms less than 7 days
• CTSS less than 8 with disease duration less than 5-7 days
• Viremia phase (high fever with normal CRP and CT)
• Severe disease
• Identify: RR >30/min, SpO2 <90% in room air
• Manage
• Respiratory support
 • Consider broad spectrum antibiotic for possible superadded bacterial pneumonia/ infection
• Inj Dexamethasone 6mg IV od for 5-10 days
• Anticoagulation – unless contraindicated full anticoagulation with enoxaparin 1mg/kg SC BD
in patients with D dimer >3-5x ULN and those with a raising D dimer
• Antivirals may be considered if duration of illness is less than 10-14 days
• Tocilizumab maybe considered when all of the criteria are met
• Severe disease
• Significantly raised markers
• No active bacterial/ fungal infection
• Supportive measures
• Maintain euvolemia
• Monitoring – as previously shown
• Management of cytokine storm - Tocilizumab
Post discharge
• Anticoagulation
• Not needed in all patients
• Employ individualized risk stratification of thrombotic and bleeding risk, to
consider patients with elevated VTE risk. Options include Apixaban 2.5mg bid
and Rivaroxaban 10mg od
• Corticosteroid therapy – advisable to continue course of 10 days if the
patient was discharged prematurely
• Oxygen therapy – short term may be needed in patients who remain
hypoxemic at rest
• Adjuvant therapies – case to case basis
Post covid symptoms
• Fever – treat symptomatically. Look for secondary causes
• Cough
• Rule out super-infections
• Graded physical activity
• Medication when indicated
• Breathlessness
• Tends to improve with breathing exercises
• Monitor saturation
• Oxygen therapy if needed
• Lung fibrosis
• Largely reversible in most patients within a period of 3-4 months
• Antifibrotic drugs can be started after pulmonologist opinion
Emerging therapies
• Piroxicam – observed improvement in oxygen saturation
• Colchicine – anti-inflammatory effect
• Tofacitinib/ Baricitinib – when CRP fails to fall or signs of clinical
deterioration noted
• Bevacizumab – being tried in severe COVID-19
• 2-Deoxy-D-Glucose – improvement in vital signs noted
• Virafin – pegylated interferon

NOT RECOMMENDED CURRENTLY