What is the management for SARS (Severe Acute Respiratory Syndrome) COVID (Coronavirus Disease)-19?

Management of SARS COVID-19

Systemic corticosteroids and anticoagulation are strongly recommended for hospitalized COVID-19 patients requiring oxygen support, while IL-6 receptor antagonists are conditionally recommended for those with severe disease. 1

Initial Assessment and Triage

• Hospitalization should be considered based on age, comorbidities, respiratory rate, and oxygen saturation 2
• Every patient admitted without a recent PCR test should be tested immediately 2
• Patients with hypoxemia (SpO2 <90%) despite oxygen therapy, dyspnea, or high respiratory rate should be admitted to intensive care 2

Respiratory Support

Oxygen Therapy and Ventilation

• For hypoxemic respiratory failure, a conditional recommendation is made for high-flow nasal oxygen (HFNC) or continuous positive airway pressure (CPAP) 1
• HFNC and CPAP should be used with healthcare professionals wearing full personal protective equipment due to aerosol generation concerns 1
• For patients requiring invasive mechanical ventilation, implement lung-protective ventilation strategies 1:
  • Low tidal volumes (4-8 mL/kg predicted body weight) 3
  • Adequate positive end-expiratory pressure (PEEP) 3
  • Maintain plateau pressure <30 cm H2O 3
• Early prone positioning is recommended for severe ARDS (PaO₂/FiO₂ ≤100 mm Hg) 1
• Consider veno-venous extracorporeal membrane oxygenation (ECMO) only for the most severe ARDS cases when other strategies have failed 1

Pharmacological Management

Strongly Recommended Treatments

• Systemic corticosteroids: Strongly recommended for patients requiring supplementary oxygen or ventilatory support 1
  • Dexamethasone decreases mortality in severe or critical COVID-19 2
• Anticoagulation: Strongly recommended for all hospitalized patients 1
  • Consider intensified thromboprophylaxis in patients with additional risk factors (obesity, known thrombophilia, intensive care treatment, or elevated D-dimers) 2

Conditionally Recommended Treatments

• IL-6 receptor antagonist monoclonal antibody treatment: Conditionally recommended for patients with hypoxemic respiratory failure 1
• Remdesivir:
  • FDA-approved for hospitalized patients and non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression 4
  • However, the ERS guideline makes a conditional recommendation against remdesivir in patients requiring invasive mechanical ventilation 1
  • No recommendation was made for remdesivir in patients requiring supplemental oxygen 1

Not Recommended Treatments

• Strong recommendations against:
  • Hydroxychloroquine 1
  • Lopinavir-ritonavir 1
• Conditional recommendations against:
  • Azithromycin 1
  • Hydroxychloroquine combined with azithromycin 1
  • Colchicine 1

Infection Control Measures

• Healthcare workers performing aerosol-generating procedures should use fitted respirator masks (N95, FFP2, or equivalent) plus other PPE (gloves, gown, eye protection) 1
• Patients diagnosed with COVID-19 should be placed in single rooms, avoiding positive pressure rooms 1
• Healthcare workers must wear appropriate protective equipment (gloves, gowns, face shield, FFP2 mask) and practice careful hand disinfection 1

Special Considerations

• For patients with hematological malignancies, deferral of cellular therapy such as HSCT or CAR-T is recommended in case of SARS-CoV-2 infection 1
• Non-chemotherapy target drugs such as JAK2-inhibitors and TKI/BTKi should not be discontinued, even in patients with COVID-19 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Not Requiring Oxygen)

• Supportive care 1
• Consider remdesivir for high-risk outpatients 4

Moderate Disease (Requiring Supplementary Oxygen)

• Systemic corticosteroids 1
• Anticoagulation 1
• Consider IL-6 receptor antagonists 1

Severe Disease (Requiring NIV Support)

• All treatments for moderate disease plus:
• HFNC or CPAP for hypoxemic respiratory failure 1
• Close monitoring for deterioration and need for intubation 1

Critical Disease (Requiring Invasive Mechanical Ventilation)

• All treatments for severe disease plus:
• Lung-protective ventilation strategies 1, 3
• Consider prone positioning 1
• Consider ECMO for refractory hypoxemia 1

Common Pitfalls and Caveats

• Delaying intubation in patients who fail to respond to noninvasive approaches may increase mortality 1
• The application of CPAP and HFNC should not delay intubation in deteriorating patients 1
• Empirical broad-spectrum antibiotics should be rapidly de-escalated based on microbiology test results and clinical response 1
• The evidence base for COVID-19 management continues to evolve rapidly, requiring regular updates to treatment protocols 1