COVID-19 patient treatment

COVID-19 patient

Mild disease Moderate disease

Severe disease

Any one of:
1. Respiratory rate > 24/min, breathlessness 2. SpO2: 90% to < 93% on room air

Any one of:
1. Respiratory rate >30/min, breathlessness 2. SpO2 < 90% on room air

Upper respiratory tract symptoms (&/or fever) WITHOUT shortness of breath or hypoxia

Home Isolation & Care

MUST DOs

✓ Physicaldistancing,indoormask use, strict hand hygiene.

✓ Symptomatic management (hydration, anti-pyretics, anti- tussive, multivitamins).

✓ Stay in contact with treating physician.

✓ Monitortemperatureandoxygen saturation (by applying a SpO2 probe to fingers).

Seek immediate medical attention if: o Difficulty in breathing
o High grade fever/severe cough,

particularly if lasting for >5 days o A low threshold to be kept for those with any of the high-risk

features*

MAY DOs

Therapies based on low certainty of evidence

➢ Tab Ivermectin (200 mcg/kg once a day for 3 days). Avoid in pregnant and lactating women.
OR

➢ Tab HCQ (400 mg BD for 1 day f/b
400 mg OD for 4 days) unless
contraindicated.

❖ InhalationalBudesonide(given

via Metered dose inhaler/ Dry powder inhaler) at a dose of 800 mcg BD for 5 days) to be given if symptoms (fever and/or cough) are persistent beyond 5 days of disease onset.

ADMIT IN WARD

Oxygen Support:

➢ Target SpO2: 92-96% (88-92% in patients with COPD).

➢ Preferred devices for oxygenation: non-rebreathing face mask.

➢ Awake proning encouraged in all patients requiring supplemental oxygen therapy (sequential position changes every 2 hours).
Anti-inflammatory or immunomodulatory therapy

➢ Inj. Methylprednisolone 0.5 to 1 mg/kg in 2 divided
doses (or an equivalent dose of dexamethasone) usually
for a duration of 5 to 10 days.

➢ Patients may be initiated or switched to oral route if
stable and/or improving.
Anticoagulation

➢ Conventional dose prophylactic unfractionated heparin

or Low Molecular Weight Heparin (weight based e.g., enoxaparin 0.5mg/kg per day SC). There should be no contraindication or high risk of bleeding.

Monitoring

➢ ClinicalMonitoring:Workofbreathing,Hemodynamic
instability, Change in oxygen requirement.

➢ Serial CXR; HRCT chest to be done ONLY If there is worsening.

➢ Lab monitoring: CRP and D-dimer 48 to 72 hrly; CBC, KFT, LFT 24 to 48 hrly; IL-6 levels to be done if deteriorating (subject to availability).

ADMIT IN ICU

Respiratory support

• Consider use of NIV (Helmet or face mask interface
depending on availability) in patients with increasing
oxygen requirement, if work of breathing is LOW.

• Consider use of HFNC in patients with increasing oxygen
requirement.

• Intubation should be prioritized in patients with high
work of breathing /if NIV is not tolerated.

• Use conventional ARDSnet protocol for ventilatory
management.
Anti-inflammatory or immunomodulatory therapy

• Inj Methylprednisolone 1 to 2mg/kg IV in 2 divided

doses (or an equivalent dose of dexamethasone) usually for a duration 5 to 10 days.

Anticoagulation
• Weight based intermediate dose prophylactic

unfractionated heparin or Low Molecular Weight Heparin (e.g., Enoxaparin 0.5mg/kg per dose SC BD). There should be no contraindication or high risk of bleeding.

Supportive measures

• Maintain euvolemia (if available, use dynamic measures
for assessing fluid responsiveness).

• If sepsis/septic shock: manage as per existing protocol
and local antibiogram.
•
Monitoring

• Serial CXR; HRCT chest to be done ONLY if there is
worsening.

• Lab monitoring: CRP and D-dimer 24-48 hourly; CBC,
KFT, LFT daily; IL-6 to be done if deteriorating (subject to availability).

After clinical improvement, discharge as per revised discharge criteria.

EUA/Off label use (based on limited available evidence and only in specific circumstances):

➢ Remdesivir (EUA) may be considered ONLY in patients with
o Moderate to severe disease (requiring SUPPLEMENTAL OXYGEN), AND
o No renal or hepatic dysfunction (eGFR <30 ml/min/m2; AST/ALT >5 times ULN (Not an

absolute contradiction), AND
o Who are within 10 days of onset of symptom/s.

❖ Recommended dose: 200 mg IV on day 1 f/b 100 mg IV OD for next 4 days. o Not to be used in patients who are NOT on oxygen support or in home settings

➢ Tocilizumab (Off-label) may be considered when ALL OF THE BELOW CRITERIA ARE MET
o Presence of severe disease (preferably within 24 to 48 hours of onset of severe

disease/ICU admission).
o Significantly raised inflammatory markers (CRP &/or IL-6). o Not improving despite use of steroids.
o No active bacterial/fungal/tubercular infection.

❖ Recommended single dose: 4 to 6 mg/kg (400 mg in 60kg adult) in 100 ml NS over 1 hour.

➢ Convalescent plasma (Off label) may be considered ONLY WHEN FOLLOWING CRITERIA ARE MET
o Early moderate disease (preferably within 7 days of symptom onset, no use after 7 days). o Availability of high titre donor plasma (Signal to cut-off ratio (S/O) >3.5 or equivalent

depending on the test kit being used).

*High-risk for severe disease or mortality

✓ Age>60years

✓ Cardiovascular disease, hypertension, and CAD

✓ DM (Diabetes mellitus) and other immunocompromised
states

✓ Chronic lung/kidney/liver disease

✓ Cerebrovascular disease

✓ Obesity

Department of Medicine, AIIMS (ND)

AIIMS/ ICMR-COVID-19 National Task Force/Joint Monitoring Group (Dte.GHS)

Ministry of Health & Family Welfare, Government of India

CLINICAL GUIDANCE FOR MANAGEMENT OF ADULT COVID-19 PATIENTS