Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected
WHO. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. World Health Organization, 2020, March 13
Review written by:
Matthew Stolman, edited by Lillian Zerihun
Green: These are extensive and evidence-based clinical management guidelines from WHO
These were developed by a multidisciplinary panel of health care providers with experience in the clinical management of patients with COVID-19 and other viral infections, as well as sepsis and ARDS. The document flags interventions with labels for strongly recommended / best practices, harmful, and those to consider with caution.
The document addresses: 1) The background of COVID-19 2) Screening and triage 3) Infection prevention and control 4) Collection of specimens 5) Management of mild, severe, and critical SARI 6) Adjunctive therapies 7) Caring for vulnerable populations including pregnant women, infants/children and older persons 8) Clinical research and specific treatments
Oxygen therapy (page 7):
Approximately 14% of COVID-19 patients will develop severe acute respiratory infection and respiratory distress (including hypoxemia, cyanosis, shock, coma, or convulsions) and should receive oxygen at 5L/min with up-titration to a target SpO2 of ≥ 94%.
Mechanical ventilation (pages 8-9):
Most critically ill patients will require mechanical ventilation, particularly those with hypoxemic respiratory failure in ARDS who fail standard oxygen therapy. Mechanical ventilation should be performed with pre-oxygenation (100% FiO2 via face mask) using airborne precautions. For adult and pediatric patients with acute respiratory distress syndrome (ARDS), lower tidal volumes (4–8 mL/kg predicted body weight, PBW), lower inspiratory pressures (plateau pressure < 30 cmH2O), and higher PEEP should be used. In children, a lower level of plateau pressure (< 28 cmH2O) is targeted, and lower target of pH is permitted (7.15–7.30). In adult patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended. Pregnant women may benefit from left lateral decubitus positioning. Patients that fail lung protective ventilation strategies should be placed on extracorporeal membrane oxygenation (ECMO) if possible.
Fluid resuscitation (pages 10-11)
Conservative fluid management is recommended to prevent worsening of ARDS. For septic patients, fluid resuscitation for adults should include a 250–500 mL crystalloid fluid as rapid bolus in the first 15–30 minutes followed by reassessment for signs of fluid overload after each bolus. For children, give 10–20 mL/kg in the first 30–60 minutes. DO NOT use hypotonic crystalloids. If there is no response to fluid loading or signs of volume overload appear, reduce or discontinue fluids. The initial BP target is MAP ≥ 65 mmHg in adults and improvement of markers of perfusion.
Vasopressors (page 11)
Vasopressors include norepinephrine, epinephrine, vasopressin, and dopamine. These are recommended to manage hypotension to a target MAP >65 and improvement in perfusion markers. In adults, administer vasopressors when shock persists during or after fluid resuscitation. They are most safely given through a central venous catheter, but are also safely administered via peripheral vein or intraosseous needle.
Give empiric antimicrobials to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour of initial patient assessment for patients with sepsis.
Do not routinely give systemic corticosteroids outside of clinical trials.
Prevention of complications include VTE, ulcer, and GI prophylaxis.
There is a proposed benefit of anticoagulation with LMWH in critically ill COVID-19 patients.
Many of the proposed guidelines are based on management of other severe viral pneumonias and were written in the context of evolving evidence for COVID-19. Thus, many of the guidelines are subject to change as emerging data alters and influences specific aspects of management.