Table 1.
Challenges in clinical management
| Recommendations | |
|---|---|
| Epidemiology and clinical features | |
| Prediction of disease trajectory from the time of symptom onset is difficult | Support research to develop and validate prognostic tools and biomarkers |
| Diagnosis | |
| Clinical features are non-specific; risk of missing a case early in a local outbreak is substantial | Adopt a low threshold for diagnostic testing, where available |
| Sensitivity of RT-PCR assays for critically ill patients is unknown | Repeat the sampling if necessary, preferably from lower respiratory tract |
| RT-PCR assays might not be available in many ICUs; if available, assays will take time to complete | Maintain a high index of suspicion for COVID-19 |
| Management of acute respiratory failure | |
| Benefits of NIV and HFNC, and associated risks of viral transmission through aerosolisation, are unclear | Reserve for mild ARDS, with airborne precautions, preferably in single rooms, and a low threshold for intubation |
| Intubation poses a risk of viral transmission to health-care workers | Perform intubation drills; the most skilled operator should intubate with full PPE and limited bag-mask ventilation |
| ECMO is extremely resource-intensive, even if centralised at designated centres | Balance the needs of a larger number of patients with less severe disease against the (unproven) benefit to a few |
| Other intensive care management | |
| Patients often develop myocardial dysfunction in addition to acute respiratory failure | Administer fluids cautiously for hypovolaemia, preferably with assessments for pre-load responsiveness; detect myocardial involvement early with troponin and beta-natriuretic peptide measurements and echocardiography |
| Bacterial and influenza pneumonia or co-infection are difficult to distinguish from COVID-19 alone | Consider empirical broad-spectrum antibiotics and neuraminidase inhibitors at presentation and subsequent rapid de-escalation |
| Benefits and risks of systemic corticosteroids are unclear | Avoid routine use until more evidence is available |
| Transfer out of the ICU for investigations such as CT scans poses risk of viral transmission | Minimise transfers by using alternatives such as point-of-care ultrasound |
| Viral shedding in the upper respiratory tract continues beyond 10 days after symptom onset in severe COVID-19 | De-isolate patients only after clinical recovery and two negative RT-PCR assays performed 24 h apart |
| Repurposed and experimental therapies that are not supported by strong evidence are being used | Seek expert guidance from local or international societies and enrol patients in clinical studies where possible |
ARDS=acute respiratory distress syndrome. COVID-19=coronavirus disease 2019. ECMO=extracorporeal membrane oxygenation. HFNC=high-flow nasal cannula. ICU=intensive care unit. NIV=non-invasive ventilation. PPE=personal protective equipment.