Management of COVID-19

Management of COVID-19 is usually done through supportive care, which may include fluid therapy, oxygen support, and supporting other affected vital organs.[1][2][3] The CDC recommends those who suspect they carry the virus wear a simple face mask.[4] Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure, but its benefits are still under consideration.[5][6] Personal hygiene and a healthy lifestyle and diet have been recommended to improve immunity.[7] Supportive treatments may be useful in those with mild symptoms at the early stage of infection.[8]

The WHO, the Chinese National Health Commission, and the United States' National Institutes of Health have published recommendations for taking care of people who are hospitalised with COVID‑19.[9][10][11] Intensivists and pulmonologists in the U.S. have compiled treatment recommendations from various agencies into a free resource, the IBCC.[12][13]

Medications
See also: Coronavirus disease 2019 § Research

Per the World Health Organization, as of April 2020, there is no specific treatment for COVID‑19.[14] On 1 May 2020, the United States gave emergency use authorization (not full approval) for remdesivir in people hospitalized with severe COVID‑19 after a study suggested it reduced the duration of recovery.[15][16] Researchers continue working on more effective treatments and many vaccine candidates are in development or testing phases.

For symptoms

For symptoms, some medical professionals recommend paracetamol (acetaminophen) over ibuprofen for first-line use.[17][18][19] The WHO and NIH do not oppose the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for symptoms,[9][20] and the FDA says currently there is no evidence that NSAIDs worsen COVID‑19 symptoms.[21]

While theoretical concerns have been raised about ACE inhibitors and angiotensin receptor blockers, as of 19 March 2020, these are not sufficient to justify stopping these medications.[9][22][23][24] One study from 22 April found that people with COVID‑19 and hypertension had lower all-cause mortality when on these medications.[25]

Steroids, such as methylprednisolone, are not recommended unless the disease is complicated by acute respiratory distress syndrome.[26][27]

The Australasian Society of Clinical Immunology and Allergy recommends that tocilizumab be considered an off-label treatment option for those with COVID‑19-related acute respiratory distress syndrome. It recommends this because of its known benefit in cytokine storm caused by a specific cancer treatment, and that cytokine storm may be a significant contributor to mortality in severe COVID‑19.[28]

Medications to prevent blood clotting have been suggested for treatment,[29] and anticoagulant therapy with low molecular weight heparin appears to be associated with better outcomes in severe COVID‐19 showing signs of coagulopathy (elevated D-dimer).[30]

Protective equipment
See also: Shortages related to the COVID-19 pandemic
The U.S. Centers for Disease Control and Prevention (CDC) recommends four steps to putting on personal protective equipment (PPE).[31]

Precautions must be taken to minimise the risk of virus transmission, especially in healthcare settings when performing procedures that can generate aerosols, such as intubation or hand ventilation.[32] For healthcare professionals caring for people with COVID‑19, the CDC recommends placing the person in an Airborne Infection Isolation Room (AIIR) in addition to using standard precautions, contact precautions, and airborne precautions.[33]

The CDC outlines the guidelines for the use of personal protective equipment (PPE) during the pandemic. The recommended gear is a PPE gown, respirator or facemask, eye protection, and medical gloves.[34][35]

When available, respirators (instead of face masks) are preferred.[36] N95 respirators are approved for industrial settings but the FDA has authorised the masks for use under an emergency use authorization (EUA). They are designed to protect from airborne particles like dust but effectiveness against a specific biological agent is not guaranteed for off-label uses.[37] When masks are not available, the CDC recommends using face shields or, as a last resort, homemade masks.[38]

Mechanical ventilation

Most cases of COVID‑19 are not severe enough to require mechanical ventilation or alternatives, but a percentage of cases are.[39][40] The type of respiratory support for individuals with COVID‑19 related respiratory failure is being actively studied for people in the hospital, with some evidence that intubation can be avoided with a high flow nasal cannula or bi-level positive airway pressure.[41] Whether either of these two leads to the same benefit for people who are critically ill is not known.[42] Some doctors prefer staying with invasive mechanical ventilation when available because this technique limits the spread of aerosol particles compared to a high flow nasal cannula.[39]

Mechanical ventilation had been performed in 79% of critically ill people in hospital including 62% who previously received other treatment. Of these 41% died, according to one study in the United States.[43]

Severe cases are most common in older adults (those older than 60 years,[39] and especially those older than 80 years).[44] Many developed countries do not have enough hospital beds per capita, which limits a health system's capacity to handle a sudden spike in the number of COVID‑19 cases severe enough to require hospitalisation.[45] This limited capacity is a significant driver behind calls to flatten the curve.[45] One study in China found 5% were admitted to intensive care units, 2.3% needed mechanical support of ventilation, and 1.4% died.[5] In China, approximately 30% of people in hospital with COVID‑19 are eventually admitted to ICU.[46]

Acute respiratory distress syndrome
Main article: Acute respiratory distress syndrome

Mechanical ventilation becomes more complex as acute respiratory distress syndrome (ARDS) develops in COVID‑19 and oxygenation becomes increasingly difficult.[47] Ventilators capable of pressure control modes and high PEEP[48] are needed to maximise oxygen delivery while minimising the risk of ventilator-associated lung injury and pneumothorax.[49] High PEEP may not be available on older ventilators.

Options for ARDS[47]
Therapy Recommendations
High-flow nasal oxygen For SpO2 <93%. May prevent the need for intubation and ventilation
Tidal volume 6mL per kg and can be reduced to 4mL/kg
Plateau airway pressure Keep below 30 cmH2O if possible (high respiratory rate (35 per minute) may be required)
Positive end-expiratory pressure Moderate to high levels
Prone positioning For worsening oxygenation
Fluid management Goal is a negative balance of 0.5–1.0L per day
Antibiotics For secondary bacterial infections
Glucocorticoids Not recommended

Experimental treatment
See also: § Research

Research into potential treatments started in January 2020,[50] and several antiviral drugs are in clinical trials.[51][52] Remdesivir appears to be the most promising.[53] Although new medications may take until 2021 to develop,[54] several of the medications being tested are already approved for other uses or are already in advanced testing.[55] Antiviral medication may be tried in people with severe disease.[1] The WHO recommended volunteers take part in trials of the effectiveness and safety of potential treatments.[56]

The FDA has granted temporary authorisation to convalescent plasma as an experimental treatment in cases where the person's life is seriously or immediately threatened. It has not undergone the clinical studies needed to show it is safe and effective for the disease.[57][58][59]

Information technology
See also: Contact tracing and Government by algorithm

In February 2020, China launched a mobile app to deal with the disease outbreak.[60] Users are asked to enter their name and ID number. The app can detect 'close contact' using surveillance data and therefore a potential risk of infection. Every user can also check the status of three other users. If a potential risk is detected, the app not only recommends self-quarantine, it also alerts local health officials.[61]

Big data analytics on cellphone data, facial recognition technology, mobile phone tracking, and artificial intelligence are used to track infected people and people whom they contacted in South Korea, Taiwan, and Singapore.[62][63] In March 2020, the Israeli government enabled security agencies to track mobile phone data of people supposed to have coronavirus. According to the Israeli government, the measure was taken to enforce quarantine and protect those who may come into contact with infected citizens. The Association for Civil Rights in Israel, however, said the move was "a dangerous precedent and a slippery slope".[64] Also in March 2020, Deutsche Telekom shared aggregated phone location data with the German federal government agency, Robert Koch Institute, to research and prevent the spread of the virus.[65] Russia deployed facial recognition technology to detect quarantine breakers.[66] Italian regional health commissioner Giulio Gallera said he has been informed by mobile phone operators that "40% of people are continuing to move around anyway".[67] The German Government conducted a 48-hour weekend hackathon, which had more than 42,000 participants.[68][69] Three million people in the UK used an app developed by King's College London and Zoe to track people with COVID‑19 symptoms.[70][71] The president of Estonia, Kersti Kaljulaid, made a global call for creative solutions against the spread of coronavirus.[72]

Psychological support
See also: Mental health during the COVID-19 pandemic

Individuals may experience distress from quarantine, travel restrictions, side effects of treatment, or fear of the infection itself. To address these concerns, the National Health Commission of China published a national guideline for psychological crisis intervention on 27 January 2020.[73][74]

The Lancet published a 14-page call for action focusing on the UK and stated conditions were such that a range of mental health issues was likely to become more common. BBC quoted Rory O'Connor in saying, "Increased social isolation, loneliness, health anxiety, stress, and an economic downturn are a perfect storm to harm people's mental health and wellbeing."[75][76]

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