Caring for Critically Ill Coronavirus Patients

To manage critically ill novel coronavirus patients, health care providers may have to draw from experience treatment pneumonias and respiratory illnesses, according to a clinical update published in JAMA Insights.

Investigators from Canada and Hong Kong discussed issues surrounding regions where the critical care units have the ability to provide mechanical ventilation. However, they understand that this ability does not exist everywhere and where it does exist, the capacity could be exceeded in many places. Managing this coronavirus outbreak “will likely have a substantial influence on patient outcomes,” they wrote.

They noted that case-fatality proportions were 7-fold higher in patients in Hubei Province — the source of the outbreak in China—compared to place outside the region (2.9% vs. 0.4%, respectively). This, to the study authors, highlighted the importance of health system capacity to care for patients who are critically ill with coronavirus.

Some of the factors that can contribute to requiring critical care include older age and comorbid conditions (such as diabetes and cardiac disease). As many as 40% of patients who required critical care so far had underlying health conditions. Most often, critical care has been needed to provide respiratory support: two-thirds of those patients have met criteria for acute respiratory distress syndrome (ARDS).

To differentiate the coronavirus from other infections, such as the flu, use upper or lower respiratory tract samples for PCR and bacterial cultures, the study authors suggested. Efficient patient care and the ability to structure infection control policies can be based off the speed of diagnostic testing results, they said.

The study authors also said that managing coronavirus is not much different from managing most viral pneumonia. Most severe coronavirus patients develop ARDS, and evidence-based treatment guidelines should be followed, the study authors said. Some of these strategies include conservative fluid strategies, empirical early antibiotics, lung-protective ventilation, prone positioning, and consideration of extracorporeal membrane oxygen for refractory hypoxemia, they explained. A high-flow nasal oxygen or noninvasive ventilation may be options when there is limited access to invasive ventilation.

A minority of coronavirus patients have already been enrolled in clinical trials. Some severely ill patients have received numerous potentially targeted therapies, the study authors added, such as neuraminidase inhibitors and corticosteroids. No antiviral or immunomodulatory therapies for coronavirus have been proved to be effective, the study authors said.

Septic shock and acute kidney injury (as well as other organ dysfunction) effects a significant portion of severe coronavirus and are associated with increased mortality, the study authors said. Mortality among all patients ranges from 0.5% to 4%, though among patients who require hospitalization, that number can jump to 5% to 15%. There is a wider range for critically ill coronavirus patients, from 22% to 62%, according to the study authors.

They also had suggestions for protecting patients and health care workers, which included keeping appropriate distance between them and using personal protective equipment and isolation rooms.

“Clinicians involved with aerosol-generating procedures such as endotracheal intubation and diagnostic testing using bronchoscopy should additionally use airborne precautions, including N95 respirators or equivalent face masks and face shields or goggles for eye protection,” they wrote.

Health care facilities also need to be prepared for a surge of coronavirus patients, the study authors urged. They should allocate resources and determine policies especially if there is eventually expected to be limited access to interventions that could save lives, such as hospital beds, ventilators, extracorporeal membrane oxygenation, or renal replacement therapies.

Without knowing what specific treatment strategies are effective, the risk-benefit ratio for commonly used treatments like corticosteroids remains unclear, the study authors said.

“Preventing transmission and slowing the rate of new infections are the primary goals; however, the concern of COVID-19 causing critical illness and death is at the core of public anxiety,” the study authors concluded.

For the most recent case counts in the COVID-19 outbreak, check out the Contagion® Outbreak Monitor.