| ENHANCED PRECAUTIONS: N95 mask* (or equivalent), gloves, gown, eye protection; disposable stethoscope; airborne infection isolation room for aerosol-generating procedures |
| Diagnostic testing | Actions | Explanatory notes |
| Nasopharyngeal swab | - Perform SARS-CoV-2 (COVID-19) test
- Test for influenza if prevalent in the community
- Do not obtain viral cultures
| - In intubated patients, tracheal aspirates and nonbronchoscopic alveolar lavage ("mini-BAL") are also acceptable.
- Bronchoscopy is only performed for this indication when upper respiratory samples and mini-BAL are negative.
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| Other microbiology | - Obtain the following:
- Blood cultures, if clinically indicated
- Sputum culture, if clinically indicated (avoid induced sputum)
- Urinary antigen for Legionella, Pneumococcus, if clinically indicated
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| Baseline laboratory testing | - Obtain the following:¶
- CBC with differential counts
- Urinalysis
- Chemistry panel including LFTs
- Troponin and BNP at baseline, and subsequently as indicated
- Consider biomarkers at baseline and for interval monitoring if indicated: procalcitonin, ferritin, CRP, CPK, D-dimer, triglycerides, fibrinogen, LDH
| - Neutrophilia is uncommon while lymphopenia is common, resulting in a high ratio (>50) of neutrophils:lymphocytes.
- Elevated LFTs are common.
- Procalcitonin is often low early in illness.
- Lymphopenia and elevation of LDH, ferritin, and CRP are associated with disease progression and need for mechanical ventilation.
- The decision for interval monitoring is institution-specific.
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| Imaging | - Obtain portable chest radiograph
- POC ultrasound may provide additional information
- CT only in patients with an indication that would change management
| - Main role of POC ultrasound is to identify other causes of respiratory compromise (eg, pneumothorax, pleural effusion, pericardial effusion, heart failure) or other contributors to hypotensive shock.
- Characteristic findings on POC ultrasound in COVID-19 pneumonia are nonspecific and include pleural thickening and B lines.
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| ECG | - Baseline at admission
- Subsequent ECGs for patients on medications that can prolong QTc or patients with troponin elevation
| - Medications that can prolong QTc include (among others): azithromycin, hydroxychloroquine, remdesivir, phenothiazines, quetiapine.
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| Flexible bronchoscopy | - Avoid bronchoscopy to prevent aerosol spread unless indicated for reasons other than diagnosis
- If necessary, perform in airborne infection isolation room
| - Bronchoscopy, should only be performed for the diagnosis of COVID-19 when upper respiratory samples and mini-BAL are negative or when indicated for another reason (eg, infection in an immunosuppressed patient; life-threatening hemoptysis or airway obstruction).
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| Supportive care | Actions | Explanatory notes |
| Management is largely supportive with surveillance for common complications including ARDS, acute kidney injury, elevated liver enzymes, and cardiac injury. All coinfections and comorbidities should be managed. Patients should be monitored for prolonged QTc interval and for any drug interactions. | |
| Goals of care | - Recommend early discussion and involvement of palliative care team as necessary
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| Vascular access | - Place central venous catheter if indicated (eg, ventilated patient)
- Place arterial line if frequent need for ABGs anticipated (eg, ventilated patient with ARDS) or blood pressure monitoring is needed
- Bundle procedures to minimize exposure; review procedure checklist before entering room
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| IV fluids and nutrition | - Conservative approach. Use vasopressors preferentially rather than large volume (>30 mL/kg) IV fluid resuscitation; monitor renal functions.
- Follow standard ICU protocols for nutritional support
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| Nebulizer treatments | - Avoid nebulizers whenever possible to prevent aerosol spread
- Use MDIs for inhaled medications (including patients on mechanical ventilation)
- When required for some patients with asthma and COPD exacerbation, give nebulizers in an airborne infection isolation room
| - If MDIs are not available, the patients may be able to use their own supply.
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| Oxygen/respiratory support | - Goal SpO2 88 to 96%
- May give NC up to 6 L/minute or NRB up to 10 L/minute
- Use of HFNC preferred over NIV. Each institution should have a policy outlining management approach.
- HFNC and NIV increase risk of aerosolization; use surgical mask over HFNC or NIV interfaces
- NIV may be preferred for indications with known benefit (eg, acute hypercapnia due to COPD exacerbation or ACHF)
- Reassess patients on HFNC and NIV every 1 to 2 hours, or sooner if SpO2 <90 or clinical deterioration
| - Some experts advocate placing a surgical mask on patients wearing low-flow oxygen devices, although the efficacy of this approach is unclear. It may be appropriate if the patient is not in an airborne isolation room or during transport.
- Special attention should be paid to using SpO2 targets in patients with dark skin tones, given data that report overestimation of SpO2 and risk of occult hypoxemia in these populations.
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| Tracheal intubation and mechanical ventilation | Actions | Explanatory notes |
| Indications | - Rapid progression over hours
- Persistent need for high flows/FiO2 (eg, >60 L/minute and an FiO2 >0.6)
- Evolving hypercapnia, increasing work of breathing, increasing tidal volume, worsening mental status, increasing duration and depth of desaturations
- Hemodynamic instability or multiorgan failure
| - Do not delay intubation until the patient has features of impending respiratory arrest (eg, respiratory rate >30/minutes, accessory muscle use, abdominal paradox) or is on maximum noninvasive supportive care since this approach is potentially harmful to both the patient and healthcare workers.
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| Rapid sequence intubation | - Performed by experienced intubator
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| Ventilator settings | - Provide low TV ventilation:
- AC with TV target 6 mL/kg IBW
- PEEP/FiO2: PEEP 10 to 15 cm H2O to start
- Titrate oxygen to target PaO2 55 to 80/SpO2 88 to 96 for most patients
- Plateau pressure <30 cm H2O
| - ARDSNet provides a guide to PEEP and FiO2 titration; refer to UpToDate text for details.
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| Prone ventilation | - Suggest prone positioning should low TV ventilation fail (eg, P/F ratio <150 mmHg × 12 hours, FiO2 requirement ≥0.6, requirement for PEEP ≥5 cm H2O)
- Advise daily prone position for 12 to 16 hours/day
- Need experienced staff; ensure that ETT and vascular access remain secured when turning
| - Effects of prone ventilation typically seen over 4 to 8 hours; improvements continue the longer it is used.
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| Additional rescue therapies | - For patients who fail prone ventilation (eg, P/F ratio <150 mmHg while prone), may consider the following interventions:
- Recruitment maneuvers and high PEEP strategies
- Trial of inhaled pulmonary vasodilators such as NO/epoprostenol
- Neuromuscular blockade for patients with refractory hypoxemia (eg, P/F ratio <100 mmHg) or ventilator dyssynchrony
- ECMO as a last resort; however, ECMO is not universally available
| - Please refer to UpToDate topic text for details on how to perform recruitment maneuvers and administer higher than usual levels of PEEP.
- Pulmonary vasodilators should not be administered unless a specific protocol and staff experienced in their administration are in place. Inhaled vasodilators may increase aerosolization.
- Numerical improvement due to pulmonary vasodilators should not prevent prone positioning when otherwise indicated.
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| Pharmacotherapy | Actions | Explanatory notes |
| Implement ICU protocols for sedation, analgesia, neuromuscular blockade (if needed), stress ulcer prophylaxis, thromboembolism prophylaxis, glucose control | |
| Empiric antibiotics | - For suspected bacterial coinfection (eg, elevated WBC, positive sputum culture, positive urinary antigen, atypical chest imaging), administer empiric coverage for community-acquired or healthcare-associated pneumonia
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| COVID-19-specific therapy | - COVID-19-specific therapy, including dexamethasone, remdesivir, and interleukin-6 inhibitors should be considered. Therapies are evolving.
| - Refer to other UpToDate content for details.
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| Glucocorticoids for non-COVID-19 illnesses | - Give glucocorticoids for other indications (eg, asthma, COPD)
| - Refer to other UpToDate content for details.
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| Adjustments to outpatient meds | Actions | Explanatory notes |
| Assess and seek expert consultation to manage comorbid conditions (asthma, COPD, sickle cell disease, immunocompromise, pregnancy) | |
| ICS | - For asthma, continue usual dose
- For COPD without asthmatic component or clear prior benefit, hold ICS
- For COPD with asthmatic component or clear prior benefit, continue ICS
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| NSAIDs | - Acetaminophen is preferred antipyretic
| - There are minimal data informing the risks of NSAIDs in the setting of COVID-19. Given the uncertainty, we use acetaminophen as the preferred antipyretic agent.
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| ACEi/ARBs | - Continue if there is no other reason for discontinuation (eg, hypotension, acute kidney injury)
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| Statins | - Patients taking a statin at baseline should continue
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