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 DOsTherapies 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 usedtoo 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