What are the primary recommendations for supportive care in patients with COVID-19?

Primary Recommendations for Supportive Care in COVID-19

Supportive care for COVID-19 should focus on oxygen therapy, corticosteroids for patients requiring oxygen, anticoagulation, and appropriate respiratory support based on disease severity, while providing psychological support to both patients and healthcare providers. 1, 2

Disease Severity Classification and Initial Assessment

Disease severity guides treatment approach:

• Mild: Various symptoms without respiratory distress
• Moderate: Lower respiratory disease with SpO2 ≥94% on room air
• Severe: SpO2 <94% on room air or respiratory rate >30 breaths/min
• Critical: Requires ICU admission or mechanical ventilation 2

Respiratory Support

Oxygen Therapy

• Target: Maintain SpO2 ≥94% (or 90-96% in patients at risk of hypercapnic respiratory failure) 1
• Delivery methods (escalating as needed):
  1. Low-flow nasal cannula
  2. High-flow nasal cannula (HFNC)
  3. Continuous positive airway pressure (CPAP)
  4. Non-invasive ventilation (NIV)
  5. Invasive mechanical ventilation 1, 2

Key Considerations for Respiratory Support

• HFNC or CPAP is conditionally recommended for patients with hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation 1
• Awake prone positioning may improve oxygenation for patients on HFNC or NIV 2
• Monitor for deterioration: Patients may worsen rapidly, requiring escalation of respiratory support 2, 3
• Low tidal volume ventilation should be used for patients requiring invasive mechanical ventilation 1

Pharmacological Interventions

Corticosteroids

• Strong recommendation for corticosteroids in patients requiring oxygen, NIV, or invasive mechanical ventilation 1, 2
• Dexamethasone 6 mg daily for up to 10 days is the standard regimen 1, 2
• Do not use corticosteroids in patients not requiring oxygen 1

Anticoagulation

• Strong recommendation for some form of anticoagulation in all hospitalized patients 1, 2
• Consider intensified prophylaxis for patients with additional risk factors 2

IL-6 Receptor Antagonists

• Conditional recommendation for IL-6 receptor antagonist monoclonal antibody therapy (tocilizumab) in patients requiring oxygen or ventilatory support, particularly with elevated inflammatory markers 1, 2
• Do not use in patients not requiring supplementary oxygen 1

Antiviral Therapy

• Nirmatrelvir-ritonavir is suggested for high-risk outpatients 2
• Remdesivir: No clear recommendation for patients requiring supplemental oxygen; conditionally recommended against use in patients requiring invasive mechanical ventilation 1, 2

Management of Complications

Thromboprophylaxis

• Standard prophylaxis for thrombosis is recommended for all hospitalized patients 2
• Monitor for development of venous thromboembolism 2

Secondary Infections

• Empirical antibiotics are not routinely recommended for non-critically ill patients 2
• Consider empirical antibiotics only when bacterial co-infection is suspected 2

Psychological and Palliative Support

Patient Support

• Provide psychological support for patients with serious COVID-19 1
• Address spiritual needs as appropriate 1
• Consider advance care planning early, especially for elderly or chronically ill patients 1

Family Support

• Bereavement support should be offered to family members of deceased patients 1
• Facilitate remote communication between patients and families when in-person visits are restricted 1

Healthcare Provider Support

• Healthcare staff caring for COVID-19 patients should be offered psychological support 1
• Team debriefs and peer support can help manage accumulated stress and grief 1

Discharge Criteria and Follow-up

• Patients can be discharged when:
  • Temperature normal for >3 days
  • Respiratory symptoms significantly improved
  • Significant absorption of pulmonary lesions on imaging
  • Two consecutive negative tests (where applicable) 2
• Schedule follow-up 1-2 weeks after diagnosis 2
• Early discharge with home oxygen therapy should be approached with caution and strict criteria, as it may lead to higher readmission rates 4

Common Pitfalls to Avoid

1. Delayed recognition of deterioration: COVID-19 patients may not exhibit significant dyspnea despite severe hypoxemia ("silent hypoxemia") 3
2. Premature discharge: Patients requiring oxygen typically need 8 days of oxygen therapy and 12 days of hospitalization 3
3. Inadequate monitoring: Persistent inflammation (elevated CRP) may continue until discharge 3
4. Overuse of unproven therapies: Avoid hydroxychloroquine, lopinavir-ritonavir, and other therapies without proven benefit 1, 5
5. Neglecting psychological impact: Both patients and healthcare providers need psychological support 1

By following these evidence-based recommendations for supportive care, clinicians can optimize outcomes for patients with COVID-19 while efficiently utilizing healthcare resources.