COVID-19: Winter is COMING!

Abstract

Coronavirus disease-2019 (COVID-19) pandemic has battered the healthcare system of India recently. Though the mortality rate is low but the mortality itself is high. In this issue, dedicated to COVID-19, the authors have presented a concise and directed look at the pieces of evidence for COVID-19. Today, there is a plethora of information available on COVID-19 but the same does not translate into true knowledge. This issue serves as the one-point reference for pieces of evidence on various critical aspects of COVID-19. As winters are approaching and air pollution will again be bothering the healthcare system, these times are vital for preparing ourselves and resources for a long and exhaustive battle.

How to cite this article: Chaudhry D, Kumar P, Singh PK, Govindagoudar MB. COVID-19: Winter is COMING! Indian J Crit Care Med 2020;24(Suppl 5):S223–S224.

Coronavirus disease-2019 (COVID-19) has been pulling the strings of the Indian healthcare system for the past few months. It is now about to celebrate its first anniversary of existence. As per the Ministry of Health and Family Welfare, the daily case count is finally on a declining trend.¹ It is unfair to the medical research community, to say that little is known about this disease. Since it was first described, a plethora of knowledge has been acquired through various researches across the globe. Though “the information” is still far more than the “Knowledge”, good quality evidence is becoming available. Evidence and management have changed drastically, and in some manners diagonally, e.g., in the initial release of clinical management guidance, World Health Organization was against the routine use of corticosteroids, whereas currently, steroids are the only drugs backed by evidence and biological plausibility.² In this supplementary issue of the Indian Journal of Critical Care Medicine, the available evidence for the management has been covered efficiently in a gist.

In the current surplus of COVID knowledge, this supplementary issue is of vital importance. COVID-19 pandemic has been preceded and later paralleled by the Pandemic of Information as well. As an example, PubMed contains over 63,000 articles only on COVID-19 in just about 9 months. The current practice of medicine relies on the principle of an evidence-based approach. Every clinician looks up for evidence to find answers to specific questions during times of dilemma. It is a herculean task to do the same in such an ever-expanding and unending ocean of information. COVID-19 has not only caused publication biases but also reputed journals have got their credibility questioned over the hurry in publishing.³ In this hour of need, the contributing authors of this issue have done a commendable job of picking up and presenting the pearls of wisdom out of the vast ocean of COVID-19 knowledge.

This issue has covered all the major aspects of COVID-19 management in critical care settings. Several of the usually neglected issues like procedures during COVID-19 have also found their due space. Different societies have issued their specific guidelines for conducting procedures but most of them have overlooked the same in critical care settings. Incidentally detected COVID-19 positive cases among those who are planned for non-COVID-19-related procedures are rising in number, but still most of the procedures are being done on patients who are in intensive care units (ICUs) due to COVID-19 disease. These issues have been addressed comprehensively in two separate sections.

Apart from this, the society has also issued an update on its previously released position statement.⁴ This section of the issue takes up the matter of management of critically ill COVID-19 patients. COVID-19 is a highly dynamic situation and the evidence related to COVID-19 is even more so. Several trials like RECOVERY and SOLIDARITY have made public their results which have a telling influence on the COVID-19 management worldwide. Previously, most of the guidelines were based on either the expert opinions or the in vitro study results. The updated statement is much more refined and focused on the current best practices. Even though there has not been much-improved survival among invasively ventilated patients, there is a remarkable reduction in overall mortality and the number of patients requiring intubation by the timely use of steroids, anticoagulants, and antiviral medications. This latest version of the position statement is currently the most concise and up-to-date document, summarizing the management of critically ill COVID-19 patients.

Airway management is an integral part of handling any critically ill patient and in the era of COVID-19, it needs special attention. Several publications have raised concerns over the extreme aerosol-generating abilities of such procedures as intubations, laryngoscopies, or even diagnostic bronchoscopies. Some researchers have even suggested the use of acrylic chambers which can be used as intubation boxes.⁵ In addition, various techniques of respiratory support can end up being high-intensity aerosol-generating sources. Authors in previously published articles have described novel clinical techniques to halt or reduce the generation and spread of contagion.⁶ All these aspects of airway management need to be and have been covered in the index issue in an efficient “to the point” manner.

The key to pandemic control or management is to avoid spread. Healthcare facilities, by being the most important public places during such times, can act as the hub of infection spread. Infection control in the hospital is not only necessary to make the hospital a safe place to be in but also to protect the frontliners of the battle against the virus. Any healthcare personnel getting infected in COVID-19 can turn out to be a great loss. Precious, scarce, and skilled human resources will not able to contribute to the fight against COVID-19 when they themselves are infected with it. Health policies related to infection control have been neglected and ignored for a long time but COVID-19, acting as a great teacher, has reminded us of the utmost importance of infection control practices. The policy of infection control is not a matter of option anymore. It is a must-have tool in the armamentarium of an intensivist. Protecting patients from cross-infection as well as the protection of health-care professionals (HCPs) should be given paramount importance.

In conclusion, we are delighted to present to you the special supplementary issue of IJCCM on COVID-19. We are hopeful that it will serve the readers, intensivists, and clinicians as a one-point referral resource on the common practices in ICU management of COVID-19 patients. Forthcoming, even the policymakers should be able to derive up-to-date information in this rapidly evolving situation. Mortality has come down, the number of cases is declining, and recovery rates are rising, but this is not the time to sit back and relax. COVID-19 is going to be a long battle. Winter is coming and before that Diwali and associated air pollution is going to batter the lung hard. The need for respiratory as well as ICUs will go up. On the contrary, it is time to tighten our seat belts as the ride is going to be a bumpy one.