Journal article

View all Respiratory Digests

Severe Covid-19

Author(s): Berlin DA, Gulick RM, Martinez FJ

N Engl J Med. 2020 May 15

Respiratory critical care
Respiratory infections
General respiratory patient care
Public health
Respiratory intensive care

Digest Author(s): Stylianos Loukides, e-Learning Director / 17 May, 2020

Severe coronavirus disease 2019 (Covid-19) typically begins after 1 week after the clinical onset of the disease. It is usually characterized by the presence of ARDS. Severe Covid-19 in adults is defined as dyspnea, a respiratory rate of 30 or more breaths per minute, a blood oxygen saturation of 93% or less, a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2:FiO2) of less than 300 mm Hg, or infiltrates in more than 50% of the lung field within 24 to 48 hours from the onset of symptoms. Endotracheal intubation is an important step for the severe patient. Early intubation seems to be the most proper approach since the risk of sudden respiratory arrest with a chaotic emergency intubation exposes staff to a greater risk of infection. The model of mechanical ventilation (lung-protective ventilation with plateau pressure less than or equal to 30 cm of water and with tidal volumes based on the patient’s height) and the prone position are potential treatment strategies for the mechanically ventilated patient. Thrombosis due to hypercoagulation and complications like renal failure are quite critical for the patients' prognosis. Treatment options are quite restricted since data from randomized and well designed studies is lacking at the moment. Preliminary data from a randomized, placebo-controlled trial involving patients with severe Covid-19 infection suggest that the investigational antiviral remdesivir shortens time to recovery. However, no effect on mortality was observed.

What we really need is to clearly define the patients at risk. Retrieving clinical data, laboratory data or combining both may help us to establish a clinical score or/and a definition that could help us to define those patients. The early definition could guide us to initiate treatment strategies earlier and using a more phenotyping approach.

5 major recommendations:

  • Careful monitoring
  • Early recognition of the severe disease
  • Sedatation and prone position
  • Prevention of thrombosis
  • Treatment of complications