What is the recommended inpatient management for COVID-19 (Coronavirus Disease 2019) pneumonia?

Inpatient Management of COVID-19 Pneumonia

The cornerstone of inpatient management for COVID-19 pneumonia includes corticosteroids (dexamethasone) for patients requiring oxygen, appropriate respiratory support escalation, anticoagulation, and consideration of remdesivir, while avoiding ineffective therapies such as hydroxychloroquine and lopinavir-ritonavir. 1

Respiratory Support

Initial Oxygen Therapy

• Start oxygen therapy when SpO2 is persistently below 94%
• Target oxygen saturation: 88-95%
• Initial approach: nasal cannula or mask oxygen at 5 L/min, titrated to achieve target saturation 2

Respiratory Support Escalation Pathway

1. High-Flow Nasal Oxygen (HFNO)

   • Consider when standard oxygen fails to maintain SpO2 >93%
   • Initial settings: 30-40 L/min flow and 50-60% FiO2
   • Adjust based on oxygenation status 2

2. Continuous Positive Airway Pressure (CPAP)

   • Consider for patients with hypoxemic acute respiratory failure without immediate indication for invasive ventilation
   • Can be delivered through helmet or facemask 1
   • May be combined with intermittent HFNO
   • Use with caution in patients with hemodynamic instability, multiple organ failure, or altered mental status 2

3. Invasive Mechanical Ventilation

   • Implement when ARDS persists or worsens despite HFNO/CPAP
   • Use protective lung ventilation strategy:
     • Lower tidal volume (4-6 ml/kg)
     • Lower plateau pressure (<30 cmH2O) 2
   • Consider prone positioning for patients with severe ARDS 1

CAUTION: CPAP and HFNO are classified as aerosol-generating procedures; use appropriate personal protective equipment. Do not delay intubation in patients failing to respond to non-invasive approaches. 1

Pharmacological Management

Corticosteroids

• Strong recommendation for patients requiring oxygen support 1
• Dexamethasone 6 mg daily for up to 10 days 1
• Do NOT use corticosteroids in patients not requiring oxygen 1

Antiviral Therapy

• Remdesivir:
  • For adults and pediatric patients weighing ≥40 kg: 200 mg IV loading dose on day 1, followed by 100 mg IV daily 3
  • Duration:
    • 5 days for hospitalized patients not requiring mechanical ventilation
    • Consider extension to 10 days if no clinical improvement
    • 10 days for patients requiring mechanical ventilation/ECMO 3
  • No clear recommendation for patients not requiring mechanical ventilation 1
  • Not recommended for patients requiring invasive mechanical ventilation 1

IL-6 Receptor Antagonists

• Consider for hospitalized patients requiring oxygen or ventilatory support
• Not recommended for patients not requiring supplementary oxygen 1

Anticoagulation

• Strongly recommended for all hospitalized COVID-19 patients 1
• Use low-molecular-weight heparin or heparin for thromboprophylaxis 1

Medications to AVOID

• Hydroxychloroquine: Strong recommendation against use 1
• Lopinavir-ritonavir: Strong recommendation against use 1
• Azithromycin: Not recommended unless bacterial infection is present 1
• Hydroxychloroquine + azithromycin combination: Not recommended 1
• Colchicine: Not recommended for hospitalized patients 1
• Interferon-β: Not recommended 1

Supportive Care

Nutritional Support

• Screen patients for nutritional risk using NRS2002 score
• For scores <3: Provide protein-rich foods and carbohydrate-containing diets
  • Target energy intake: 25-30 kcal/kg/day
  • Target protein intake: 1.5 g/kg/day
• For scores ≥3: Provide early nutritional support
  • Oral nutrition supplements with ≥18g protein/time, 2-3 times/day
  • Consider enteral nutrition tube when oral intake is inadequate 1

Additional Supportive Measures

• Consider H2 receptor antagonists or proton pump inhibitors for patients with gastrointestinal bleeding risk factors 1
• Monitor and maintain water and electrolyte balance 2
• Maintain acid-base homeostasis 2
• Regular monitoring of laboratory parameters:
  • Complete blood count
  • CRP, PCT
  • Liver and kidney function tests
  • Coagulation profile
  • Arterial blood gas analysis 2
• Serial chest imaging to track disease progression 2

Monitoring and Discharge Criteria

Continuous Monitoring

• Vital signs: heart rate, oxygen saturation, respiratory rate, blood pressure
• Laboratory tests as outlined above
• Serial chest imaging 2

Discharge Criteria

• Body temperature returned to normal for >3 days
• Respiratory symptoms significantly improved
• Lung inflammation shows obvious signs of absorption
• Negative respiratory nucleic acid tests on two consecutive days 2

Common Pitfalls to Avoid

1. Delaying corticosteroid therapy in patients requiring oxygen
2. Using corticosteroids in patients not requiring oxygen
3. Administering ineffective therapies (hydroxychloroquine, lopinavir-ritonavir)
4. Delaying intubation when non-invasive ventilation is failing
5. Neglecting thromboprophylaxis
6. Overlooking nutritional support
7. Inappropriate use of antibiotics without evidence of bacterial co-infection

The evidence strongly supports the use of corticosteroids for patients requiring oxygen, while highlighting the importance of appropriate respiratory support escalation and anticoagulation. The benefit of remdesivir appears modest, with potential reduction in time to recovery but no significant mortality benefit 4.