Treatment of COVID-19 Pneumonia
The treatment of COVID-19 pneumonia requires a structured approach focusing on oxygen therapy, corticosteroids, antivirals, and supportive care, with methylprednisolone 40-80 mg/day recommended for patients with severe illness or rapid disease progression. 1
Oxygen Therapy and Respiratory Support
- Start supplemental oxygen when SpO2 is persistently below 94% 1, 2
- Target SpO2 of 88-95% for oxygen therapy 1, 2
- Escalation pathway based on severity:
- Nasal cannula or mask oxygen (non-rebreather masks preferred when possible) 1, 3
- High-flow nasal oxygen (HFNO) for patients with higher oxygen requirements 1, 3
- Non-invasive ventilation (NIV) with caution due to aerosol generation 3
- Invasive mechanical ventilation for patients with respiratory distress 1
Important: Hypoxemia alone should not trigger intubation as it is often remarkably well tolerated in COVID-19. Intubate based on signs of respiratory distress rather than refractory hypoxemia alone. 4, 2
Corticosteroid Therapy
- Methylprednisolone 40-80 mg/day (not exceeding 2 mg/kg/day) for patients with:
- Rapid disease progression
- Severe illness 1
- Short duration of 3-5 days is recommended 5
- Avoid routine use of corticosteroids unless specifically indicated 5
Antiviral Treatment
- Remdesivir is recommended as primary antiviral treatment:
- 200 mg IV loading dose on day 1
- 100 mg IV daily for 5-10 days depending on patient condition 1
Management of Septic Shock
- Recognize septic shock when infection is confirmed/suspected and vasopressors are needed to maintain MAP ≥65 mmHg with lactate ≥2 mmol/L 5
- Resuscitation protocol:
- At least 30 ml/kg of isotonic crystalloid for adults in first 3 hours
- Avoid hypotonic crystalloids, starches, or gelatins
- Norepinephrine as first-choice vasopressor 5
Thromboembolism Prophylaxis
- Enhanced prophylaxis against thromboembolism is important, especially for:
Antibiotics for Bacterial Co-infection
- Avoid inappropriate use of broad-spectrum antibiotics 5, 1
- Consider empiric antibiotics only for suspected bacterial co-infection:
- Amoxicillin, azithromycin, or fluoroquinolones for mild cases
- Broader coverage for severe cases with de-escalation once culture results are available 1
Monitoring and Supportive Care
Regular laboratory monitoring:
- Complete blood count
- CRP, PCT
- Liver and kidney function tests
- Coagulation profile
- Arterial blood gas analysis
- Serial chest imaging 1
Continuous monitoring of vital signs:
- Heart rate
- Oxygen saturation
- Respiratory rate
- Blood pressure 1
Supportive care:
- Ensure sufficient energy intake
- Maintain water and electrolyte balance
- Monitor acid-base homeostasis 1
Immunomodulatory Therapy
- Tocilizumab may be considered for patients receiving corticosteroids, as it showed a 4.6% absolute reduction in mortality at day 28 compared to standard of care 7
Prone Positioning
- Consider awake prone positioning for non-intubated hypoxemic patients 2
- For intubated patients with refractory hypoxemia (PaO2/FiO2 < 150 mmHg), prone positioning for 12-16 hours is recommended 2
Discharge Criteria
- Body temperature returned to normal for more than 3 days
- Respiratory symptoms significantly improved
- Lung inflammation shows obvious signs of absorption
- Negative respiratory nucleic acid tests on two consecutive days 5
Caution: Older patients (>60 years), those with COPD, chronic smokers, and those with severe COVID-19 may require longer oxygen therapy in the post-COVID period 8, and should be monitored closely before discharge.