International Pulmonologists consensus on COVID-19

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Salient Points

The following article focuses on epidemiology, noted clinical features, mode of transmission, diagnostic features, initial management, treatment options, prognostic factors and prevention of COVID-19 infection .

  1. Transmission:
  • Droplet transmission
  • Other possible modes of transmission
  1. Clinical Features
  2. Diagnosis
    1. Suspected case
    2. Probable Case
    3. Confirmed Case
    4. Close Contacts
    5. Lab findings – Cell counts, Inflammatory markers
    6. Diagnostic tests
  3. Treatment
    1. Antiviral therapy
    2. Other treatment options
  4. Prognostic factors
    1. General
    2. Risk factors
  5. Prevention
    1. Contact
    2. Fomites
    3. PPE

Detailed Summary

  • Transmission – Droplets, Aerosols, Fomites
  • One study suggested that the virus may also be present in feces and could contaminate places like toilet bowls and bathroom sinks.
  • In February a Chinese newborn was diagnosed with the new coronavirus just 30 hours after birth. The baby’s mother tested positive before she gave birth. It is unclear how the disease was transmitted – in the womb, or after birth.
  • Clinical Features
  • The exact incubation period is not known. It is presumed to be between 2 to 14 days after exposure, with most cases occurring within 5 days after exposure.
  • Spectrum of illness severity
  1. Mild illness was reported in 81% patients
  2. Severe illness ( Hypoxemia, >50% lung involvement on imaging within 24 to 48 hours) in 14%
  3. Critical Disease (Respiratory failure, shock, multi-organ dysfunction syndrome) was reported in 5 percent.

Overall case fatality rate was between 2.3 to 5%

Clinical Features 

  • Fever in 88%
  • Fatigue in 38%
  • Dry cough in 67%
  • Myalgias in 14.9%
  • Dyspnea in 18.7%

Pneumonia appears to be the most common and severe manifestation of infection. In this group of patients breathing difficulty developed after a median of five days of illness. Acute respiratory distress syndrome developed in 3.4% of patients.

Other symptoms

  • Headache
  • Sore throat
  • Rhinorrhea
  • Gastrointestinal symptoms

About 80% of confirmed COVID-19 cases suffer from only mild to moderate disease and nearly 13% have severe disease.

Diagnosis

  • Case Definition
  1. Suspected Case
  2. Probable Case
  3. Confirmed Case
  4. Close Case
  • Lab findings
  1. White Blood Cell Count –  It does not provide accurate information about COVID-19. Leukopenia, leukocytosis, and lymphopenia have been reported. Lymphopenia is more common, seen in more than 80% of patients. Mild thrombocytopenia is commonly seen. However thrombocytopenia is considered as a poor prognostic sign.
  2. INFLAMMATORY MARKERS –
    1. Serum Procalcitonin is often normal at the time of admission; however it increases in patients who require ICU care.
    2. In one study high D-Dimer and lymphopenia are associated with poor prognosis.
    3. CRP – COVID-19 increases CRP. This seems to be associated with disease severity and prognosis. In patients suffering from severe respiratory failure with a normal CRP level, an alternative diagnosis should always be sought.
    4. Patients who meet the criteria for suspect cases, should undergo testing for SARS-CoV-2 and also respiratory pathogens. Respiratory specimen collection from the upper and in particular lower respiratory tract should be performed under strict airborne infection control precautions. Preferably these samples should be obtained as early as symptom onset, since it yields higher virus concentrations.

Current Recommended Diagnostic Modalities for COVID-19

  • SARS-CoV-2 RNA is detected by RT-PCR – Results are generally available within a few hours to 2 days. A single positive test should be confirmed by a second RT-PCR assay targeting a different SARS-CoV-2 gene. If initial testing is negative but the suspicion for COVID-19 remains, the WHO recommends re-sampling and testing from multiple respiratory tract sites.
  • For safety reasons, specimens from a patient with suspected or documented COVID-19 should not be submitted for viral culture. Samples should also be tested for other viral/bacterial pathogens.

Treatment Options

  1. Mild Disease –  An upper respiratory tract viral infection, low grade fever, cough, malaise, rhinorrhoea, sore throat without any warning signs, shortness of breath, haemoptysis, Gastro-Intestinal symptoms: Nausea, vomiting, Diarrhea, Without change in mental status ( ie: confusion, lethargy), Non immunocompromised.

Management – Consider home isolation

  1. Severe Disease (14%) – Respiratory rate > 30/min,  SPo2- <93%,  PaO2/FiO2 <300 • Lung infiltrates >50% within 24- 48 hours
  2. Critically ill (5%) – Respiratory failure (need of mechanical ventilation), Septic shock • MODS
  • Management of both Severe and Critically ill patients require ICU admission.
  • Possible treatment options:
  1. Antiviral therapy – Remdesivir –  Dose: Adult: 200mg IV on day 1(loading dose) followed by 100mg IV OD x 9 days, Pediatric: < 40 kg: 5 mg/kg IV on day 1, then 2.5 mg/kg IV q24h, Lopinavir/Ritonavir combination –  Dose: Adult: 400/100mg PO Q12h,
    Pediatric: Pediatric (based on lopinavir):
    Oral solution < 15kg: 12mg/kg/DOSE q12h,
    15-40kg: 10mg/kg/DOSE q12h
    >40kg: 400mg q12h
    Oral tablet
    ≥15-25kg: 200mg q12h
    ≥25-35kg: 300mg q12h
    >35kg: 400mg q12h
  2. ACEi/ARBs
  3. Interferons
  4. CHLOROQUINE/HYDROXYCHLOROQUINE –  Dose (Adult) : 400mg PO Q12h x 1 day, 200mg PO Q12h x 4 days
    Pediatric: 6.5mg/kg/DOSE PO q12h x 1 day, then 3.25mg/kg/DOSE PO q12h x 4 days (up to adult maximum dose)
  5. TOCILIZUMAB
  6. Ascorbic Acid
  7. Antibacterial Therapy

General Prognosis

The vast majority of infected patients (>80%) don’t get significantly ill and don’t require hospitalization.

Among hospitalized patients, 10-20% of patients are admitted to ICU, 3-10% require intubation, 2-5% die.

Epidemiological risk factors

  • Older Age
  • Male sex
  • Medical comorbidities
  • Chronic pulmonary diseases
  • Cardiovascular disease
  • Chronic kidney disease
  • Diabetes

Prevention

  • PPE for at-risk health facilities
  • Airborne precautions for aerosolized generating procedures: Gloves Gloves nitrile, powder-free, non-sterile.
  • Medical masks, good breathability, internal and external faces should be clearly identified.
  • Face Shield Made of clear plastic and provides good visibility to both the wearer and the patient, Adjustable band to attach firmly around the head and fit snugly against the forehead, Fog resistant (preferable), Completely cover the sides and length of the face, May be re-usable (made of robust material which can be cleaned and disinfected) or disposable. Particulate respirator, grade N95 or higher N95 or FFP2 respirator or higher Good breathability with design that does not collapse against the mouth (e.g. duckbill, cup-shaped)

Reference Link : https://www.unah.edu.hn/dmsdocument/9674-consenso-internacional-de-neumologos-sobre-covid-19-version-ingles

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