Clinical Guidance for Management of Adult COVID-19 Patients

Mild Disease

Upper respiratory tract symptoms (&/or fever) WITHOUT shortness of breath or hypoxia

Home Isolation & Care

MUST DOs

• Physical distancing, indoor mask use, strict hand hygiene.
• Symptomatic management (hydration, anti-pyretics, antitussive, multivitamins).
• Stay in contact with treating physician.
• Monitor temperature and oxygen saturation (by applying a SpO₂ probe to fingers).

Seek immediate medical attention if:

• Difficulty in breathing
• High grade fever/severe cough, particularly if lasting for >5 days
• A low threshold to be kept for those with any of the high-risk features*

MAY DOs
Therapies based on low certainty of evidence especially for those with high-risk of progression*

• Inhalational Budesonide (given via Metered dose inhaler/ Dry powder inhaler) at a dose of 800 mcg BD for 5 days) to be given if symptoms (fever and/or cough) are persistent beyond 5 days of disease onset.

If cough persists for more than 2-3 weeks, investigate for tuberculosis and other conditions.

Moderate disease

Any one of:

• Respiratory rate > 24/min, breathlessness
• SpO₂: 90% to < 93% on room air

ADMIT IN WARD

Oxygen Support:

• Target SpO₂: 92-96% (88-92% in patients with COPD).
• Preferred devices for oxygenation: non-rebreathing face mask.
• Awake proning encouraged in all patients requiring supplemental oxygen therapy (sequential position changes every 2 hours).

Anti-inflammatory or immunomodulatory therapy

• Inj. Methylprednisolone 0.5 to 1 mg/kg in 2 divided doses (or an equivalent dose of dexamethasone) usually for a duration of 5 to 10 days.
• Patients may be initiated or switched to oral route if stable and/or improving.
• There is no evidence for benefit for injectable steroids in those NOT requiring oxygen supplementation, or on continuation after discharge
• Anti-inflammatory or immunomodulatory therapy (such as steroids)canhaveriskof secondary infection such as invasive mucormycosis when used
  too early, at higher dose or for longer than required

Anticoagulation

• Conventional dose prophylactic unfractionated heparin or Low Molecular Weight Heparin (weight based e.g., enoxaparin 0.5mg/kg per day SC). There should be no contraindication or high risk of bleeding.

Monitoring

• Clinical Monitoring: Work of breathing, Hemodynamic instability, Change in oxygen requirement.
• Serial CXR; HRCT chest to be done ONLY If there is worsening.
• Lab monitoring: CRP and D-dimer 48 to 72 hrly; CBC, KFT, LFT 24 to 48 hourly.

After clinical improvement, discharge as per revised discharge criteria.

Severe disease

Any one of:

• Respiratory rate >30/min, breathlessness
• SpO₂ < 90% on room air

ADMIT IN ICU

Respiratory support

• Consider use of NIV (Helmet or face mask interface depending on availability) in patients with increasing oxygen requirement, if work of breathing is LOW.
• Consider use of HFNC in patients with increasing oxygen requirement.
• Intubation should be prioritized in patients with high work of breathing /if NIV is not tolerated.
• Use institutional protocol for ventilatory management when required

Anti-inflammatory or immunomodulatory therapy

• Inj Methylprednisolone 1 to 2mg/kg IV in 2 divided doses (or an equivalent dose of dexamethasone) usually for a duration 5 to 10 days.
• Anti-inflammatory or immunomodulatory therapy (such as steroids)can have risk of secondary infection such as invasive mucormycosis when used too early, at higher dose or for longer than required

Supportive measures

• Maintain euvolemia (if available, use dynamic measures for assessing fluid responsiveness).
• If sepsis/septic shock: manage as per existing protocol and local antibiogram.

Monitoring

• Clinical Monitoring: work of breathing, Hemodynamic instability, Change in oxygen requirement
• Serial CXR; HRCT chest to be done ONLY if there is worsening.
• Lab monitoring: CRP and D-dimer 24-48 hourly; CBC, KFT, LFT 24 to 48 hourly.

After clinical improvement, discharge as per revised discharge criteria.

*High-risk for severe disease or mortality

• Age > 60 years
• Cardiovascular disease, hypertension, and CAD
• DM (Diabetes mellitus) and other immunocompromised states (such as HIV)
• Active tuberculosis
• Chronic lung/kidney/liver disease
• Cerebrovascular disease
• Obesity

EUA/Off label use (based on limited available evidence and only in specific circumstances):

Remdesivir (EUA) may be considered ONLY in patients with

• 10 days of onset of symptoms, in those having moderate to severe disease (requiring supplemental oxygen), but who are NOT on IMV or ECMO
• Consider remdesivir for 5 days to treat hospitalized patients with COVID-19 (No evidence of benefit for treatment more than 5 days)
• NOT to be used in patients who are NOT on oxygen support or in home setting
• Monitor for RFT andLFT (remdesivir not recommended if eGFR<30ml/min/m2; AST/ALT >5times UNL) (not an absolute contraindication)
• Recommended dose: 200 mgIV on day 1 followed by100 mg IV OD for next 4 days

Tocilizumab may be considered when ALL OF THE BELOW CRITERIA ARE MET

• Rapidly progressing COVID-19 needing oxygen supplementation or IMV and not responding adequately to steroids (preferably within 24- 48 hours of onset of severe disease  /ICU admission)
• Preferably to be given with steroids
• No active TB, fungal, systemic bacterial infection
• Long term follow up for secondary infections (such as reactivation of TB, Flaring of Herpes etc.)
• Presence of severe disease (preferably within 24 to 48 hours of onset of severe disease/ICU admission).
• Significantly raised inflammatory markers (CRP &/or IL-6).
• Recommended single dose: 4 to 6 mg/kg (400 mg in 60kg adult) in 100 ml NS over 1 hour. 

Source : Ministry of Health & Family Welfare