Treatment of Adults with COVID-19

Only asymptomatic patients, or those with mild symptoms without  new shortness of breath or a reduction in oxygen saturation are classified as having a mild severity of illness.

All other patients should be monitored for markers of clinical deterioration including rapidly progressive respiratory failure and sepsis. This has been seen to occur most commonly between days 5- 10 after symptom onset.

In alignment with the National COVID-19 Clinical Taskforce recommendations:

1. Supplemental oxygen to maintain saturations of  92-96%.
2. Lower SpO₂ (88-92%) could be targeted in patients with pre-existing lung disease, for example chronic obstructive pulmonary disease (COPD) or pulmonary fibrosis.
3. Consider periods of prone positioning for patients receiving any form of supplemental oxygen. Ensure appropriate caution is used and that these patients are adequately monitored.
4. Consider High level respiratory support using High Flow Nasal Oxygen or non-invasive ventilation when unable to maintain SpO2 ≥ 92% despite conventional oxygen delivery at > 6 L/min or an FiO2=0.4.
5. Endotracheal intubation and mechanical ventilation when appropriate in patients who deteriorate despite optimised less invasive respiratory therapies.
6. In rare refractory cases an early referral to an ECMO centre may need to be considered.
7. If a patient’s oxygen requirements change such that a different delivery mechanism is required, delivery device should be retained with patient to support reuse at different points in patient care.

Use of HFNO and NIV does have the potential to generate aerosols. As such, it should be performed in a negative-pressure (Class N) room; if unavailable, a single (Class S) room should be used. NIV may specifically be considered appropriate, for example, in patients with a clear exacerbation of COPD or heart failure, as a ceiling of care, as a technique to delay intubation, or in situations where resources are limited.

We recommend:

1. That where clinicians decide to use HFNO or NIV, COVID-19 infection should be assumed and these be provided using similar precautions as for patients with known COVID-19.
2. That where clinicians decide to use NIV, continuous positive airway pressure (CPAP) is used in preference to bilevel positive airway pressure (BiPAP), as lung compliance is generally normal in COVID-19.

ACEM is aware of evidence from other countries whereby ventilatory management has moved away from early intubation. Patients with worsening hypercapnia, acidaemia, hypoxaemia, respiratory fatigue, haemodynamic instability or those with altered mental state will need invasive mechanical ventilation.
 
We recommend lung-protective mechanical ventilation should be employed using the following principles:

1. Low tidal volume strategy (4-8ml/kg predicted body weight).
2. Limiting plateau pressures to less than 30cm H₂O.
3. Permissive hypercapnia is usually well-tolerated and may reduce volutrauma.
4. Higher levels of positive end-expiratory pressure (PEEP) (greater than 15cm H₂O) may be needed, but should be used with caution.
5. Optimising ventilation may require Neuromuscular blockade and recruitment manoeuvres.
6. Alternate modes of ventilation such as airway pressure release ventilation (APRV) may be considered based on clinician preference and local experience

We recommend the following practices when mechanical ventilation is employed:

1. Heat and moisture exchanger (HME) filters should have viral filtration capacity and circuits should be maintained for as long as allowable (as opposed to routine changes).
2. Use of closed inline suction catheters. Any disconnection of the patient from the ventilator should be avoided to prevent lung decruitment and aerosolisation. If necessary, the endotracheal tube should be clamped and the ventilator disabled (to prevent aerosolisation).
3. Neuromuscular blockade (NMB): NMB may be considered in the setting of worsening hypoxia or hypercapnia, and in situations where the patient's respiratory drive cannot be managed with sedation alone resulting in ventilator dys-synchrony and lung decruitment.

As the evidence continues to grow, exisiting recommendations are likely to be modified.  We endorse the COVID 19 Taskforce guidance on disease modifying agents (Section 6) [Link]

We recommend:

1. Dexamethasone 6 mg daily intravenously or orally for up to 10 days in adults with COVID-19 who are receiving oxygen (including mechanically ventilated patients).
2. Do not routinely use dexamethasone to treat COVID-19 in adults who do not require oxygen.
3. Follow the taskforce guidance in regards evolving guidance pertaining to Antiviral and Immunomodulating Drugs noting that at present the conditional recommendations for Remdesivir and Sotrovomib need to be considered in Emergency department patients who meet Inclusion criteria.

Nitrous oxide use
There is currently insufficient and conflicting information about cleaning, filtering and aerosol generating potential in the setting of COVID-19 to provide definitive advice about the use of nitrous oxide during ED procedures.

Factors believed to mitigate the likelihood of aerosol generation include limiting use to fully co-operative patients, use of a face mask with a good seal rather than a mouthpiece, use of an appropriate viral filter and use of a circuit with a scavenger system.

As a result, many health services have taken the approach that nitrous oxide may continue to be used in ED for patients for whom it is the best available option.

We recommend that clinical staff should don PPE appropriate to the COVID-19 risk status of the patient, with airborne PPE recommended only for unknown or high-risk patients.
 
Procedural sedation
Procedural sedation (PS) is an example of a process that may have to be modified in the context of the pandemic. This reflects the possibility that any PS could theoretically result in the need for an aerosol generating procedure such as airway management.
 
We recommend:

1. EDs review their current processes for PS and identify whether modifications are required based on IPC requirements for COVID-19
2. Clinicians undertake a patient and procedure specific risk assessment prior to performing PS. Where the patient meets a current case definition for COVID-19 (or their risk cannot be assessed) and the procedure does not need to be performed immediately, alternate strategies should be pursued (such as management in an operating theatre).
3. Where the procedure is time critical and there is a significant risk that PS may result in an aerosol generating procedure (such as airway management), appropriate IPC precautions should be undertaken. This should include staff wearing PPE for airborne precautions.
4. A risk mitigation approach should be used wherever possible. For example, this might include using ketamine as opposed to propofol to reduce the probability that airway management is required.

The following resources were used in the preparation of this section:

• National COVID 19 Evidence Taskforce Living Guidelines. 2 Sep 2020; [Link]
• Australian and New Zealand Intensive Care Society (ANZICS). ANZICS COVID-19 Guidelines. 15 April 2020; Version 2.  [Link]
• Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015;20(8):1182–1191. doi:10.1111/resp.12620. [Link]
• Clerkin et al. COVID-19 and Cardiovascular Disease. 24 March 2020. [Link]
• NHS. Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected) 26 March 2020 Version 2. [Link]
• Rhodes, A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine: March 2017 - Volume 45 - Issue 3: 486-552. doi: 10.1097/CCM.0000000000002255. [Link]
• World Health Organisation (WHO). Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: Interim guidance. 13 March 2020. [Link]
• NHS. Clinical guide for the management of critical care for adults with COVID-19 during the coronavirus pandemic: Specialty guides for patient management during the coronavirus pandemic. 8 April 2020 Version 2. [Link]

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.