What are the current management recommendations for inpatient COVID-19 (Coronavirus Disease 2019) patients?

Management of Inpatient COVID-19 Patients

For hospitalized COVID-19 patients requiring oxygen or ventilatory support, administer dexamethasone 6 mg daily for up to 10 days and provide prophylactic anticoagulation; do not use corticosteroids in patients not requiring supplemental oxygen. 1, 2

Stratify by Oxygen Requirement

Patients NOT Requiring Supplemental Oxygen

• Do NOT administer corticosteroids - this provides no mortality benefit and causes harm (mortality 14.0% vs 17.8% in standard care vs dexamethasone groups) through immunosuppression, hyperglycemia, and increased infection risk 1, 2
• Provide prophylactic-dose anticoagulation (low molecular weight heparin preferred over unfractionated heparin) for all hospitalized COVID-19 patients regardless of oxygen requirement 1, 2, 3
• Monitor oxygen saturation at least twice daily with target SpO2 no higher than 96% if supplemental oxygen becomes necessary 2
• Monitor respiratory rate at least twice daily as this is often the earliest sign of deterioration before oxygen desaturation occurs 2

Patients Requiring Supplemental Oxygen (Non-Invasive Support)

• Initiate dexamethasone 6 mg daily immediately upon oxygen requirement for up to 10 days - this reduces mortality by 3% absolute risk reduction 1, 2, 3
• Continue prophylactic anticoagulation 1, 2, 3
• Consider IL-6 receptor antagonist monoclonal antibody therapy (tocilizumab or sarilumab) for patients with evidence of COVID-19-related inflammation despite corticosteroids 1
• Use high-flow nasal cannula (HFNC) or non-invasive CPAP (delivered through helmet or facemask) for hypoxemic acute respiratory failure without immediate indication for invasive mechanical ventilation 1, 3
• Consider awake prone positioning in patients who remain hypoxemic, but this requires close monitoring with clear failure and escalation criteria 4

Patients Requiring Invasive Mechanical Ventilation and/or ECMO

• Administer dexamethasone 6 mg daily for 10 days (total treatment duration for invasively ventilated patients) 1, 5
• Continue prophylactic anticoagulation unless contraindicated 1, 3
• Apply low tidal volume ventilation (lung protective strategy) combined with FiO2 and PEEP management 4, 6, 7
• Use prone positioning for 12-16 hours in cases of refractory hypoxemia (PaO2/FiO2 < 150 mmHg, FiO2 ≥ 0.6, and PEEP ≥ 10 cmH2O) 4, 7
• Consider remdesivir - though the European Respiratory Society made no formal recommendation for non-invasively ventilated patients and suggests against its use in invasively ventilated patients 1
• Consider adding a second immunosuppressant (IL-6 antagonist like tocilizumab/sarilumab, IL-1 antagonist like anakinra, or JAK inhibitor like baricitinib/tofacitinib) if worsening occurs despite dexamethasone and COVID-19-related inflammation is present 1

Therapies to AVOID

• Do NOT use hydroxychloroquine - strong recommendation against use in all COVID-19 patients 1, 3
• Do NOT use azithromycin unless documented bacterial coinfection exists 1, 2, 3
• Do NOT use lopinavir-ritonavir - strong recommendation against use 1, 3
• Do NOT use colchicine in hospitalized patients 1
• Do NOT use interferon-β in hospitalized patients 1, 3
• Do NOT use routine antibiotics unless there is clinical suspicion of bacterial infection 3, 7

Remdesivir Considerations (FDA-Approved)

The FDA label indicates remdesivir is approved for hospitalized COVID-19 patients, with specific dosing 5:

• Loading dose: 200 mg IV on Day 1 (adults and pediatric patients ≥40 kg)
• Maintenance dose: 100 mg IV once daily from Day 2
• Treatment duration: 5 days for non-invasively ventilated patients; 10 days for those requiring invasive mechanical ventilation/ECMO 5
• However, the European Respiratory Society made no recommendation for remdesivir in non-invasively ventilated patients and suggests against its use in invasively ventilated patients 1

Critical Monitoring Parameters

• Perform hepatic laboratory testing before starting and during treatment as clinically appropriate 5
• Determine prothrombin time before starting treatment and monitor during therapy 5
• Assess for respiratory worsening - intubate based on signs of respiratory distress (fatigue, exhaustion risk) more than refractory hypoxemia alone 4, 6
• Daily assessments for weaning readiness using low-level pressure support in ventilated patients 4

Common Pitfalls to Avoid

• Do not delay corticosteroid therapy in patients requiring oxygen - mortality benefit is time-sensitive 2, 3
• Do not give corticosteroids to non-hypoxic patients - this causes harm without benefit 1, 2, 3
• Do not delay recognition of deterioration - respiratory rate elevation and increased work of breathing often precede oxygen desaturation 2
• Do not delay intubation when non-invasive respiratory support fails or signs of exhaustion appear 3, 6
• Do not overlook anticoagulation in all hospitalized patients 2, 3
• Do not share one ventilator for multiple patients 4