Who to consult for a patient with Covid-19 (Coronavirus disease 2019) in acute respiratory distress?

Immediate Consultation for COVID-19 with Acute Respiratory Distress

For a 22-year-old man with COVID-19 in acute respiratory distress, immediately consult an expert in treating COVID-19, such as a pulmonologist, internist, or infectious disease specialist, depending on local availability. 1

Primary Consultation Pathway

• Seek immediate expert consultation when COVID-19 patients experience worsening respiratory symptoms or develop acute respiratory distress, as this represents a critical escalation requiring specialized management 1
• The most appropriate specialists to consult include:
  • Pulmonologist (preferred for respiratory expertise) 1
  • Internist with COVID-19 experience 1
  • Infectious disease specialist 1
  • The choice depends on local institutional resources and availability 1

Critical Care Escalation

• Involve intensive care specialists immediately if the patient shows signs of severe respiratory failure, as 60-70% of ICU-admitted COVID-19 patients develop acute respiratory distress syndrome (ARDS) 1
• Consider anesthesiology consultation if airway management or intubation is anticipated, as these procedures require specialized expertise and infection control protocols 1

When to Escalate to ICU-Level Care

The following clinical features warrant immediate critical care involvement:

• Severe hypoxemia despite supplemental oxygen 1
• Respiratory rate >30 breaths/minute or signs of respiratory muscle fatigue 1
• SpO2 <90% on room air or declining oxygen saturation 1
• Bilateral pulmonary infiltrates on imaging consistent with ARDS 1
• Need for mechanical ventilation consideration 1

Multidisciplinary Team Assembly

Beyond the primary respiratory specialist, assemble a team that may include:

• Critical care physicians for patients requiring intensive monitoring or mechanical ventilation 1
• Cardiologists if myocardial dysfunction develops (occurs in 20-30% of severe cases) 1
• Nephrologists if acute kidney injury occurs (10-30% of ICU patients) 1

Common Pitfalls to Avoid

• Do not delay consultation waiting for test results or imaging; clinical deterioration in COVID-19 can be rapid 1
• Do not assume young age is protective; while patients over 60 account for >80% of deaths, younger patients are not spared from severe disease 1
• Avoid managing severe respiratory distress without specialist input, as prediction of disease trajectory from symptom onset is difficult and specialized interventions (prone positioning, ECMO, specific ventilation strategies) may be needed 1
• Ensure proper PPE protocols are in place before any specialist evaluates the patient, as airborne precautions are required 1

Timing Considerations

• Median time from symptom onset to ARDS is 7-12 days, but acute deterioration can occur rapidly 1
• Early specialist involvement is crucial as the median time from symptom onset to death is 2-8 weeks, and early intervention improves outcomes 1
• Do not wait for "mild" symptoms to resolve; worsening respiratory symptoms require immediate escalation 1