What is the management for a patient with Covid-19 presenting with fever, myalgias, and acute respiratory failure?

Management of COVID-19 with Fever, Myalgias, and Acute Respiratory Failure

For a patient with COVID-19 presenting with fever, myalgias, and acute respiratory failure requiring oxygen or ventilatory support, immediately initiate corticosteroids (dexamethasone 6 mg daily), provide respiratory support escalating from high-flow nasal oxygen to mechanical ventilation as needed, administer prophylactic anticoagulation, and consider IL-6 receptor antagonist therapy. 1

Immediate Respiratory Support

Oxygen and Ventilatory Support Algorithm:

• For hypoxemic respiratory failure without immediate need for intubation: Use high-flow nasal cannula (HFNC) or noninvasive CPAP delivered through helmet or facemask as first-line noninvasive ventilatory support 1
• For worsening hypoxemia despite noninvasive support: Proceed to invasive mechanical ventilation with lung-protective strategies 2, 3
• During mechanical ventilation: Apply prone positioning, avoid excessive tidal volumes, and use conservative fluid management 2
• For refractory hypoxemia: Evaluate early for extracorporeal membrane oxygenation (ECMO) 2

The recommended treatment duration is 10 days for patients requiring invasive mechanical ventilation and/or ECMO, and 5 days for hospitalized patients not requiring invasive ventilation (extendable to 10 days if no clinical improvement) 4

Corticosteroid Therapy (Critical)

Dexamethasone 6 mg daily is strongly recommended for patients requiring oxygen, noninvasive ventilation, or invasive mechanical ventilation 1. This recommendation is based on the UK RECOVERY trial showing:

• 29.3% mortality with dexamethasone vs 41.4% with standard care in mechanically ventilated patients 1
• 23.3% mortality with dexamethasone vs 26.2% with standard care in patients requiring supplementary oxygen 1

Do NOT administer corticosteroids to COVID-19 patients not requiring supplementary oxygen, as no mortality benefit exists in this population 1

Antiviral Therapy Considerations

Remdesivir dosing for acute respiratory failure:

• Loading dose: 200 mg IV on Day 1 for patients ≥40 kg 4
• Maintenance dose: 100 mg IV once daily from Day 2 4
• Duration: 10 days for patients on invasive mechanical ventilation/ECMO; 5 days for those not requiring invasive ventilation 4

However, current guidelines suggest NOT offering remdesivir to patients requiring invasive mechanical ventilation 1. No recommendation is made for patients hospitalized without invasive ventilation 1

IL-6 Receptor Antagonist Therapy

Consider IL-6 receptor antagonist monoclonal antibody therapy (tocilizumab) for hospitalized patients requiring oxygen or ventilatory support 1. Do not offer to patients not requiring supplementary oxygen 1

Anticoagulation (Mandatory)

Administer prophylactic anticoagulation to all hospitalized COVID-19 patients 1. This addresses the hypercoagulable state characteristic of COVID-19, evidenced by elevated fibrinogen and D-dimers 1

Symptomatic Management

Fever Control

• Use acetaminophen (paracetamol) as first-line antipyretic when temperature exceeds 38.5°C 1, 5
• Dosing: Up to 2 grams per day, not exceeding 4 grams in 24 hours 6
• Continue only while fever symptoms persist 1
• Avoid NSAIDs when alternatives exist in patients with established COVID-19 infection, though no definitive evidence links NSAIDs to worse outcomes 5
• Advise fluid intake up to 2 liters daily to prevent dehydration 1

Myalgia Management

• Acetaminophen remains first-line for myalgia due to safety profile 6
• For refractory pain: Consider short-term codeine preparations (codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution) 1, 6
• Avoid NSAIDs in patients with severe COVID-19 affecting renal, cardiac, or gastrointestinal systems 6

Cough Suppression

• Encourage patients to avoid lying supine as this makes coughing ineffective 1
• For distressing cough: Use short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 1

Monitoring Requirements

Before and during treatment, perform:

• Hepatic laboratory testing before starting and during therapy 4
• Prothrombin time determination before starting and monitor as clinically appropriate 4
• Cardiac troponin monitoring if clinically indicated 1

Troponin interpretation in COVID-19:

• Mild elevations (<2-3× ULN): Do not require workup for type 1 MI unless angina or ECG changes present; explained by pre-existing cardiac disease or acute COVID-19 stress 1
• Marked elevations (>5× ULN): May indicate severe respiratory failure, shock, myocarditis, Takotsubo syndrome, or type 1 MI; consider echocardiography if no MI symptoms 1

Therapies NOT Recommended

Do NOT offer the following:

• Hydroxychloroquine (strong recommendation against) 1
• Azithromycin without bacterial infection 1
• Hydroxychloroquine + azithromycin combination 1
• Colchicine 1
• Lopinavir-ritonavir 1
• Interferon-β 1

Critical Pitfalls to Avoid

• Do not withhold corticosteroids in patients requiring oxygen support – this is the single most important mortality-reducing intervention 1
• Do not administer corticosteroids to patients not requiring oxygen – no benefit and potential harm 1
• Do not delay intubation in rapidly deteriorating patients despite availability of noninvasive options 2, 3
• Be cautious with opioid prescriptions as psychological stress from COVID-19 may increase requirements and risk of misuse 6
• Monitor for drug interactions if using remdesivir with other COVID-19 therapies 5