ENHANCED PRECAUTIONS: N95 mask* (or equivalent), gloves, gown, eye protection; disposable stethoscope; airborne infection isolation room for aerosol-generating procedures |
Diagnostic testing | Actions | Explanatory notes |
Nasopharyngeal swab | - Perform SARS-CoV-2 (COVID-19) test
- Test for influenza if prevalent in the community
- Do NOT obtain viral cultures
| - In intubated patients, tracheal aspirates and nonbronchoscopic alveolar lavage ("mini-BAL") are also acceptable.
- Bronchoscopy is only performed for this indication when upper respiratory samples and mini-BAL are negative.
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Other microbiology | - Obtain the following:
- Blood cultures, if clinically indicated
- Sputum culture, if clinically indicated (avoid induced sputum)
- Urinary antigen for Legionella, Pneumococcus, if clinically indicated
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Baseline laboratory testing | - Obtain the following:¶
- CBC with differential counts
- Urinalysis
- Chemistry panel including LFTs
- Troponin and BNP at baseline, and subsequently as indicated
- Consider biomarkers at baseline and for interval monitoring if indicated: procalcitonin, ferritin, CRP, CPK, D-dimer, triglycerides, fibrinogen, LDH
| - Neutrophilia is uncommon while lymphopenia is common, resulting in a high ratio (>50) of neutrophils:lymphocytes.
- Elevated LFTs are common.
- Procalcitonin is often low early in illness.
- Lymphopenia and elevation of LDH, ferritin, and CRP are associated with disease progression and need for mechanical ventilation.
- The decision for interval monitoring is institution-specific.
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Imaging | - Obtain portable chest radiograph
- POC ultrasound may provide additional information
- CT only in patients with an indication that would change management
| - Main role of POC ultrasound is to identify other causes of respiratory compromise (eg, pneumothorax, pleural effusion, pericardial effusion, heart failure) or other contributors to hypotensive shock.
- Characteristic findings on POC ultrasound in COVID-19 pneumonia are nonspecific and include pleural thickening and B lines.
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ECG | - Baseline at admission
- Subsequent ECGs for patients on medications that can prolong QTc or patients with troponin elevation
| - Medications that can prolong QTc include (among others): azithromycin, hydroxychloroquine, remdesivir, phenothiazines, quetiapine.
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Flexible bronchoscopy | - Avoid bronchoscopy to prevent aerosol spread unless indicated for reasons other than diagnosis
- If necessary, perform in airborne infection isolation room
| - Bronchoscopy, should only be performed for the diagnosis of COVID-19 when upper respiratory samples and mini-BAL are negative or when indicated for another reason (eg, infection in an immunosuppressed patient; life-threatening hemoptysis or airway obstruction).
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Supportive care | Actions | Explanatory notes |
Management is largely supportive with surveillance for common complications including ARDS, acute kidney injury, elevated liver enzymes, and cardiac injury. All co-infections and comorbidities should be managed. Patients should be monitored for prolonged QTc interval and for any drug interactions. | |
Goals of care | - Recommend early discussion and involvement of palliative care team as necessary
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Vascular access | - Place central venous catheter if indicated (eg, ventilated patient)
- Place arterial line if frequent need for ABGs anticipated (eg, ventilated patient with ARDS) or blood pressure monitoring is needed
- Bundle procedures to minimize exposure; review procedure checklist before entering room
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Intravenous fluids and nutrition | - Conservative approach. Use vasopressors preferentially rather than large volume (>30 mL/kg) IV fluid resuscitation; monitor renal functions.
- Follow standard ICU protocols for nutritional support
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Nebulizer treatments | - Avoid nebulizers whenever possible to prevent aerosol spread
- Use MDIs for inhaled medications (including patients on mechanical ventilation)
- When required for some patients with asthma and COPD exacerbation, give nebulizers in an airborne infection isolation room
| - If MDIs are not available, the patients may be able to use their own supply.
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Oxygen/respiratory support | - Goal SpO2 88 to 96%
- May give NC up to 6 L/minute or NRB up to 10 L/minute
- Use of HFNC preferred over NIV. Each institution should have a policy outlining management approach.
- HFNC and NIV increase risk of aerosolization; use surgical mask over HFNC or NIV interfaces
- NIV may be preferred for indications with known benefit (eg, acute hypercapnia due to COPD exacerbation or ACHF)
- Reassess patients on HFNC and NIV every 1 to 2 hours, or sooner if SpO2 <90 or clinical deterioration
| - Some experts advocate placing a surgical mask on patients wearing low-flow oxygen devices, although the efficacy of this approach is unclear. It may be appropriate if the patient is not in an airborne isolation room or during transport.
- Special attention should be paid to using SpO2 targets in patients with dark skin tones, given data that report overestimation of SpO2 and risk of occult hypoxemia in these populations.
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Tracheal intubation and mechanical ventilation | Actions | Explanatory notes |
Indications | - Rapid progression over hours
- Persistent need for high flows/fraction of inspired oxygen (eg, >60 L/minute and a fraction of inspired oxygen [FiO2] >0.6)
- Evolving hypercapnia, increasing work of breathing, increasing tidal volume, worsening mental status, increasing duration and depth of desaturations
- Hemodynamic instability or multiorgan failure
| - Do NOT delay intubation until the patient has features of impending respiratory arrest (eg, respiratory rate >30/minutes, accessory muscle use, abdominal paradox) or is on maximum noninvasive supportive care since this approach is potentially harmful to both the patient and healthcare workers
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Rapid sequence intubation | - Performed by experienced intubator
- Avoid bag valve mask ventilation: If must perform, use in-line bacterial/viral filter; 2-person technique improves seal and reduces aerosolization.
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Ventilator settings | - Provide low tidal volume ventilation:
- AC with TV target 6 mL/kg IBW
- PEEP/FiO2: PEEP 10 to 15 cm H2O to start
- Titrate oxygen to target PaO2 55 to 80/SpO2 88 to 96 for most patients
- Plateau pressure <30 cm H2O
| - ARDSNet provides a guide to PEEP and FiO2 titration; refer to UpToDate text for details.
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Prone ventilation | - Suggest prone positioning should low tidal volume ventilation fail (eg, PaO2/FiO2 [P/F] ratio <150 mmHg × 12 hours, FiO2 requirement ≥0.6, requirement for PEEP ≥5 cm H2O)
- Advise daily prone position for 12 to 16 hours/day
- Need experienced staff; ensure that ETT and vascular access remain secured when turning
| - Effects of prone ventilation typically seen over 4 to 8 hours; improvements continue the longer it is used.
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Additional rescue therapies | - For patients who fail prone ventilation (eg, P/F ratio <150 mmHg while prone), may consider the following interventions:
- Recruitment maneuvers and high PEEP strategies
- Trial of inhaled pulmonary vasodilators such as NO/epoprostenol
- Neuromuscular blockade for patients with refractory hypoxemia (eg, P/F <100 mmHg) or ventilator dyssynchrony
- ECMO as a last resort; however, ECMO is not universally available
| - Please refer to UpToDate topic text for details on how to perform recruitment maneuvers and administer higher than usual levels of PEEP.
- Pulmonary vasodilators should not be administered unless a specific protocol and staff experienced in their administration are in place. Inhaled vasodilators may increase aerosolization.
- Numerical improvement due to pulmonary vasodilators should not prevent prone positioning when otherwise indicated.
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Pharmacotherapy | Actions | Explanatory notes |
Implement ICU protocols for sedation, analgesia, neuromuscular blockade (if needed), stress ulcer prophylaxis, thromboembolism prophylaxis, glucose control | |
Empiric antibiotics | - For suspected bacterial co-infection (eg, elevated WBC, positive sputum culture, positive urinary antigen, atypical chest imaging), administer empiric coverage for community-acquired or healthcare-associated pneumonia
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COVID-19-specific therapy | - COVID-19 specific therapy, including dexamethasone, remdesivir, and interleukin-6 inhibitors should be considered. Therapies are evolving.
| - Refer to other UpToDate content for details.
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Glucocorticoids for non-COVD-19 illnesses | - Give glucocorticoids for other indications (eg, asthma, COPD)
| - Refer to other UpToDate content for details.
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Adjustments to outpatient meds | Actions | Explanatory notes |
Assess and seek expert consultation to manage comorbid conditions (asthma, COPD, sickle cell disease, immunocompromise, pregnancy) | |
ICS | - For asthma, continue usual dose
- For COPD without asthmatic component or clear prior benefit, hold ICS
- For COPD with asthmatic component or clear prior benefit, continue ICS
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NSAIDs | - Acetaminophen is preferred antipyretic
| - There are minimal data informing the risks of NSAIDs in the setting of COVID-19. Given the uncertainty, we use acetaminophen as the preferred antipyretic agent.
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ACEi/ARBs | - Continue if there is no other reason for discontinuation (eg, hypotension, acute kidney injury)
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Statins | - Patients taking a statin at baseline should continue
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