Pulmonology Book

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Corona Virus 19

Aka: Corona Virus 19, COVID-19, Covid19, SARS-CoV2
  1. See Also
    1. Intensive Care
  2. Epidemiology
    1. Corona virus that originated in bats (similar to SARS, MERS)
    2. Originally acquired at seafood and live animal market in Wuhan, Hubei Province, China in late 2019
      1. Initial International hot-spots (Feb 2020): China, Iran, Northern Italy, South Korea, Japan
      2. Initial U.S. hot spots (Feb 2020): Washington and California (sporadic cases in other regions)
        1. By middle March, Corona Virus spread to all 50 states
        2. Limited test availability hampered the identification of true cases, especially given ongoing Influenza
  3. Pathophysiology: Infectivity
    1. Person to person transmission with viral shedding 17-24 days (median 20 days) in China survivors
      1. Infectious 5 to 13 days after symptom resolution
    2. Infectivity (R0, pronounced "R-Naught")
      1. R0 appears to be 2-3 in most cases of Corona Virus 19
        1. However, there have been "super spreader" cases in which R0>20 (e.g. large gatherings)
  4. Pathophysiology: Severe Course Timing
    1. Incubation: 4 to 7 days (mean 5 days, some cases as long as 12 days)
    2. Day 0: First Symptoms (see below)
    3. Day 5: Dyspnea
    4. Day 7: Hospital Admission
    5. Day 8: Acute Respiratory Distress Syndrome (ARDS)
    6. Day 12-18: Death
    7. Day 22: Survivor hospital discharge
    8. Day 30: Recovery in mild cases (although Anosmia may persist for months)
    9. Day 60-75: Recovery in severe cases
  5. Pathophysiology: Illness stages
    1. Replication Stage
      1. Virus replicates with relatively minor symptoms
    2. Immunologic Response Stage
      1. Immune response after the first few days to week is a normal adaptive response in 80% of patients
      2. Exaggerated immunopathologic response (cytokine storm) occurs in <20% of cases
        1. Inflammatory cytokines cause tissue damage with Pneumonia and ARDS
  6. Findings: Signs and Symptoms
    1. General and prodromal
      1. Asymptomatic in 18-33% (especially younger patients)
      2. Fever (44% at initial presentation, 83-98% on hospitalization)
      3. Myalgia
      4. Fatigue
    2. Upper Respiratory
      1. Pharyngitis
    3. Cardiopulmonary
      1. Cough (46-82%)
        1. Hemoptysis may occur
        2. Cough is typically dry (but may be productive in some cases)
      2. Shortness of Breath (31%)
        1. Associated with more severe disease
      3. Hypoxia (9% of mild cases, 40% of severe cases)
        1. Patients often appear to be in little respiratory distress
        2. Yet patients often present with profound Hypoxia (even with O2 Sat 70-80%)
        3. Patients with significant respiratory distress may decompensate rapidly
    4. Cardiac
      1. Chest tightness
      2. Palpitations
    5. Gastrointestinal
      1. Decreased appetite or Anorexia (40%)
      2. Diarrhea (17%)
    6. Neurologic
      1. Headache
      2. Confusion or Altered Level of Consciousness (encephalopathy)
      3. Altered taste or smell (34% of patients)
        1. Loss of Smell Sensation (Anosmia)
        2. Altered Taste Sensation (Dysgeusia)
    7. Skin
      1. Pernio-like reactions of distal digits with erythema and swelling ("Covid Toes")
      2. Acrocyanosis
      3. Livedo Reticularis
  7. Labs
    1. COVID-19 Diagnosis (efficacy varies widely by test version, technique, timing)
      1. Antigen Tests for Corona Virus 2019
        1. Obtained via Nasopharyngeal swab (deep nasal swab) or Oropharyngeal swab
        2. Fast and inexpensive tests similar to Rapid Strep Test and Rapid Influenza Test
        3. Lower Test Sensitivity: 70-80%
      2. PCR for Corona Virus 2019
        1. Obtained via Nasopharyngeal swab (deep nasal swab) or Oropharyngeal swab
        2. Test accuracy depends on an adequate swab sample
        3. FDA approved PCR tests should have Test Sensitivity >95%, Test Specificity 100%
      3. Antibody Testing for Corona Virus 2019
        1. Unclear if Antibody confers Immunity
        2. Unclear how long Antibody confers Immunity (may be short as with seasonal Influenza)
        3. FDA approved Antibody tests should have Test Sensitivity >90% and Test Specificity >95%
        4. High False Positive Rate in low disease Prevalence regions (most of U.S. in summer 2020)
    2. Differential Diagnosis Evaluation
      1. Influenza nasopharyngeal swab
        1. Coninfection with Influenza is unlikely but possible (may occur in 5% of cases)
      2. Respiratory Virus Panel
        1. Typically includes Influenza, parainfluenza, RSV, Metapneumovirus, Rhinovirus, Adenovirus
      3. Pertussis PCR
      4. Streptococcal Pneumoniae urine antigen
      5. Legionella urine antigen
    3. Other lab findings
      1. Complete Blood Count (CBC) with Platelet Count
        1. Lymphopenia (Lymphocytes <1500/mm3) is most common (63%)
          1. More common in worse disease (present in >80% of those hospitalized)
        2. Leukocytosis (24-30%)
        3. Thrombocytopenia (associated with worse prognosis)
      2. Liver Function Test
        1. Liver transaminases (AST, ALT) mildly increased (37%)
        2. Lactate Dehydrogenase
      3. Venous Blood Gas
      4. Serum Lactate
    4. Acute phase reactants
      1. C-Reactive Protein
      2. Serum Ferritin
      3. Procalcitonin
        1. Normal on presentation
        2. Increase may suggest Bacterial Infection or severe Covid19 infection
    5. Markers of increased mortality
      1. D-Dimer (increased >1)
        1. D-Dimer >1.5 mcg/ml may prompt prophylactic Anticoagulation at some facilities
      2. Serum Troponin Increased
      3. Lymphopenia (Lymphocytes <1500/mm3)
      4. Interleukin-6 (IL-6) Increased
      5. Liver Function Test increases (AST, ALT. LDH, PT/INR increased)
      6. Serum Creatinine increased
      7. Creatine Kinase (CK) increased
      8. Serum Ferritin increased
      9. Procalcitonin Increased
    6. Other testing
      1. Blood Cultures (draw and hold first set with initial lab testing)
  8. Imaging
    1. Chest XRay
      1. Bilateral infiltrates
    2. Chest CT
      1. Bilateral regions of lung consolidation and ground glass opacities
      2. Progression from scattered ground glass findings to coalescence and then lung consolidation in the most severe cases
    3. Lung Ultrasound
      1. Survey the lungs using a systematic "lawn mower" approach
      2. Ultrasound B-Line artifacts correlate with CT ground glass findings
      3. Progression from scattered b-line artifacts to b-line coalescence and then lung consolidation (liver-like appearance)
      4. https://emcrit.org/ibcc/COVID19/#lung_ultrasonography
  9. Differential Diagnosis
    1. See Hypoxia
    2. See Dyspnea
    3. Bacterial Pneumonia
      1. Streptococcal Pneumoniae
      2. Pertussis
      3. Legionella
    4. Viral Respiratory Infections
      1. Influenza
      2. Parainfluenza
      3. Metapneumovirus
      4. Rhinovirus
      5. Adenovirus
    5. Non-Infectious Causes
      1. Pulmonary Embolism
      2. Obstructive Lung Disease (Asthma, COPD)
      3. Congestive Heart Failure
  10. Complications
    1. Precautions
      1. Complications and decompensation are more common after 7 days of illness
    2. Respiratory Effects
      1. Multi-lobar Pneumonia
      2. Acute Respiratory Distress Syndrome (ARDS)
    3. Cardiac effects
      1. Myocarditis (Cardiomyopathy with Cardiogenic Shock)
        1. May mimic Acute Coronary Syndrome (findings on EKG may be identical to STEMI)
      2. Acute Coronary Syndrome
        1. Like Influenza, COVID-19 creates a severe inflammatory response that precipitates Plaque rupture and MI
        2. Cardiology is unlikely to perform PCI on active COVID-19 patients
          1. May need to consider MI Thrombolysis (however, high risk in patients at risk of DIC)
    4. Thrombosis
      1. Venous Thromboembolism
      2. Mycocardial Infarction
      3. Cerebrovascular Accident
      4. Skin microthrombi such as Pernio (see dematologic findings as above)
      5. https://www.sciencedirect.com/science/article/pii/S0049384820301201
    5. Encephalopathy
      1. Filatov (2020) Cureus 12(3):e7352 +PMID:32328364 [PubMed]
    6. Kawasaki Disease
      1. Jones (2020) Hosp Pediatr +PMID:32265235 [PubMed]
    7. Acute Renal Failure
      1. Raza (2020) Cureus 12(6):e8429 +PMID:32642345 [PubMed]
  11. Management: General Measures
    1. See Prevention below
      1. Includes Personal Protection Equipment (N95 Mask, gown, Eye Protection and gloves) applied with donning and doffing
    2. Supportive care
      1. See ABC Management
      2. See Intensive Care
      3. See Pneumonia Management
      4. See ARDS Management
      5. Avoid aggressive fluid Resuscitation (do NOT use Sepsis level 30 cc/kg)
      6. Have Norepinephrine available for Hypotension
    3. Position Changes
      1. Consider awake prone position (as well as on their left and right lateral decubitus positions, and sitting upright)
      2. Direct patient to roll to prone position and other positions for as long as they are comfortable
      3. Proning obese patients may be difficult
        1. Consider pregnancy massage mattress
        2. https://prone2help.org
    4. Practice deep breathing Exercises
      1. Johns Hopkins
        1. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-recovery-breathing-exercises#:~:text=Phase%201%3A%20Deep%20Breathing%20While%20On%20Your%20Back&#38;text=Breathe%20in%20through%20the%20nose,deep%20breaths%20for%20one%20minute.
    5. Disposition: Home Recommendations
      1. Practice position changes and deep breath Exercises (see above)
      2. Monitor for Hypoxia (with portable Oxygen Saturation monitor)
        1. Return for Oxygen Saturations <90-92%
      3. Duration of home quarantine recommendations
        1. May discontinue isolation after 10 days if no fever for 3 days AND improved symptoms (e.g. cough)
        2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html
  12. Management: Oxygenation
    1. Precautions
      1. Oxygenation combined with position changes (see above) are the two most critical interventions
      2. Monitor oxygenation and ventilation closely and recheck patient every 1-2 hours (patient decompensate quickly)
      3. Review work of breathing, Respiratory Rate, Heart Rate, Oxygen Saturation, Capnography and other parameters
      4. Consider Endotracheal Intubation in those tiring, failing oxygenation strategies
    2. Oxygenation by Nasal Cannula and Mask
      1. Oxygen by Nasal Cannula up to 5-6 L/min (humidified if available) to maintain Oxygen Saturation 92-96%
      2. Persistent Hypoxia despite Nasal Cannula up to 5-6 L/min
        1. Non-rebreather at 15 L/min may be applied over the top of the Nasal Cannula
          1. Helps prevent aerosolization
          2. Allows for adequate oxygenation for severe Hypoxia
          3. Levitan (2020) ACEP Now (see link below)
        2. Non-Invasive Positive Pressure Ventilation (esp. HHFNC, or in some cases non-vented CPAP)
        3. Endotracheal Intubation
    3. Non-Invasive Positive Pressure Ventilation (NIPPV)
      1. Use all devices with viral filter (HEPA filter)
      2. High Flow Nasal Cannula (typically 40 to 60 L/min)
        1. Appears safer than BiPAP, CPAP without significant viral dispersion
        2. Allows for the oxygenation and increased alveolar recruitment that many with corona virus require
        3. However, anecdotally at high volume sites, High Flow Nasal Cannula appears less effective than CPAP
      3. CPAP
        1. Risk of viral dispersion
        2. If done safely, CPAP could have a significant role for alveolar recruitment
          1. https://emcrit.org/pulmcrit/cpap-covid/
        3. Safer options to limit viral dispersion
          1. Non-vented CPAP masks
          2. Helmet interface (used in Italy pandemic, not typically available in U.S.)
      4. BIPAP is not recommended
        1. CPAP alone appears adequate to overcome Atelectasis and surfactant loss
        2. BiPAP appears to add little benefit in Covid19 over CPAP, with the risk of virus dispersion
  13. Management: Endotracheal Intubation
    1. Precautions
      1. Although early intubation has been favored, NIPPV despite Hypoxia may be preferred in some patients
      2. Endotracheal Intubation is among the highest risk procedures for transmission
      3. COVID-19 patients are intubated on Mechanical Ventilation for on average 10 days
        1. See Mechanical Ventilation for potential complications
        2. Mortality of intubated patients ranges from 20-90%
      4. COVID-19 patients are difficult intubations (most experienced intubating clinician should perform)
        1. Rapid desaturation despite Apneic Oxygenation
        2. Signficant airway edema of the supraglottic region that distorts landmarks
          1. Elastic Bougie has been less helpful in these patients (not firm enough given edema)
      5. Maximize Endotracheal Tube first pass success
        1. Slow down and expect desaturation with intubation
        2. Exercise caution in Laryngoscope introduction, rotating around the Tongue
        3. Use the Levitan technique of gradual exposure of the uvula, epiglottis, aryepiglottic fold, Larynx
      6. Avoid Awake Nasotracheal Intubation
        1. Higher risk of aerosolization
        2. Nasal Intubation duration limit of 3 days is too short for COVID-19 patients
      7. Have rescue airway at bedside
        1. Attach I-Gel or LMA with HEPA Filter to ambubag with PEEP Valve
    2. Early intubation has been advocated over NIPPV (other than High Flow Nasal Cannula) for less viral transmission
      1. However, intubation puts healthcare staff at significant transmission risk
      2. Ventilators are a limited resource (Italian providers placed up to 4 patients on the same Ventilator)
        1. https://emcrit.org/pulmcrit/split-ventilators/
    3. Have a lower threshold for intubation when failing High Flow Nasal Cannula
      1. COVID-19 patients may give less warning (Hypoxemia without increased resp. effort) before rapid decompensation
      2. Rising FIO2 requirements (>75% FIO2) and high Respiratory Rate >26/min
    4. Personal Protection Equipment (PPE)
      1. See Donning and Doffing Personal Protection Equipment
      2. Providers are using Powered Air Purifying Respirator (PAPR) for intubation where available
      3. Surgical hat and gown
      4. N95 Mask beneath a surgical mask with Face Shield
        1. Ideally uses a full Face Shield or goggles
      5. Double gloves
    5. Intubation Equipment
      1. Video Laryngoscopy is preferred (allows for distance from airway) over Direct Laryngoscopy
        1. However, supraglottic inflammation or restricted mouth opening may require Direct Laryngoscope backup
        2. Consider Macintosh-Shaped Video Laryngoscopy blades (may also be used with Elastic Bougie)
      2. Endotracheal Tube with stylet and 10 cc syringe
      3. HEPA Filter
      4. CO2 Detector
      5. Dirty equipment bucket at feet of intubating provider
      6. Rescue Airway (e.g. I-Gel or LMA with HEPA Filter)
      7. Preoxygenation equipment (see below)
        1. Bag-Valve Mask (BVM) with PEEP Valve
        2. EtCO2 adapter (inline between Bag and Mask)
          1. Oxygen tubing attached and oxygen flow set at 6 L/min
        3. Viral Filter (inline between Bag and Mask)
        4. Mask
          1. Use NIPPV mask if available for better seal
    6. Rapid Sequence Intubation (with K-ROC)
      1. Ketamine and Rocuronium is the a common Sedative and paralytic combination used in these intubations
      2. Ketamine 1.5 to 2 mg/kg
      3. Rocuronium 1.5 to 2 mg/kg
    7. Preoxygenation
      1. Preoxygenation for 5 minutes without Positive Pressure Ventilation
      2. Continue Apneic Oxygenation throughout intubation, despite with expect rapid oxygen desaturation
      3. Use Rapid Sequence Intubation with Apneic Oxygenation, but avoid PPV (Bag Valve Mask or Bipap)
        1. However, Scott Weingart, MD has an innovative approach to safe preoxygenation with CPAP
        2. https://emcrit.org/emcrit/covid19-intubation-packs-and-preoxygenation-for-intubation/
    8. Safe PPE Procedure after passing Endotracheal Tube
      1. Inflate ET Tube cuff and dispose of syringe
      2. Drop stylet and Laryngoscope Blade into the dirty equipment bucket
      3. Place Laryngoscope Handle onto work surface now considered dirty
      4. Remove outer gloves
      5. Attach HEPA Filter to ET Tube (will remain in place throughout Mechanical Ventilation period)
      6. Attach CO2 detector and ambubag to confirm color change
      7. Remove only the CO2 detector (leave HEPA Filter in place) and continue ventilation
      8. Carefully evaluate ET Tube Depth (CXR may be delayed)
    9. Mechanical Ventilator settings
      1. See Mechanical Ventilation
      2. Follow ARDSnet protocols
      3. Initial Setting
        1. Use low Tidal Volumes (e.g. 6 ml/kg Ideal Body Weight)
        2. Use high Respiratory Rates (e.g. 20/min)
          1. However monitor closely for Breath Stacking (Auto-PEEP)
          2. Monitor for Hypotension (decreased Preload)
        3. May start with high FIO2 but rapidly decrease FIO2 while increasing PEEP
          1. See PEEP Table
          2. Goal Oxygen Saturation 92 to 96%
          3. FIO2 <0.4, Start with PEEP 5 cmH2O
            1. Consider Ventilator Weaning if stable on low FIO2 and low PEEP (see below)
          4. FIO2 0.4 to 0.6, Start with PEEP 10 cmH2O
            1. See Ventilator Troubleshooting (evaluate for mucous plugging, Pneumothorax, VAP)
          5. FIO2 >0.6, Start with PEEP 15 cmH2O
            1. Prone patient for 16 hours of every 24 hours if FIO2 >0.6 and PEEP >10 cmH2O
            2. Consider ECMO if persistent FIO2 and PEEP requirements
        4. Inspiratory to Expiratory Ratio (I:E) to 1:2 or 1:1.5
      4. Consider a lung recruitment maneuver at start of Mechanical Ventilation
        1. Increase Tidal Volume to 8-10 ml/kg for 10 minutes and then return to 6 ml/kg OR
        2. Increase pressure to 30 cm H2O for 30 seconds
      5. Ventilator Weaning
        1. Consider when FIO2 <0.5 and PEEP <10 cmH2O
        2. Decrease sedation and trial pressure support
      6. Monitoring
        1. Permissive hypercapnea, but keep pH >7.2 (permissive hypercapnea)
        2. Plateau pressure <30 cm H2O
        3. Follow ABG every 12 hours (and as needed for clinical worsening)
    10. Post-Intubation Sedation and Analgesia
      1. Inadequate sedation risks Post-Traumatic Stress Disorder
      2. Expect to use higher doses of sedation
        1. Patients have Respiratory Failure, but intact mentation
        2. Plan to sedate to RASS -3 to -5 (Deep Sedation )
      3. Start with Propofol and Fentanyl
      4. Add Dexmedetomidine or Midazolam
  14. Management: Lines and Fluids
    1. Left Internal Jugular Central Line
      1. Reserve right internal jugular for ECMO
    2. Arterial Line
    3. Nasogastric Tube or Orogastric Tube
    4. Urinary Catheter
    5. Maintain negative flud balance
      1. Avoid maintenance Intravenous Fluids
      2. Supply fluids through enteral feedings and the fluid in delivered medications
      3. Consider IV Furosemide (lasix) 20 mg every 8 hours
      4. If fluid bolus is required, use 20% Human Albumin
    6. Enteral Feedings (Nasogastric Tube)
      1. Use calorie dense feedings, targeting 25 kcal/kg/day
      2. Use senna 15 ml twice daily to promote regular stooling once enteral feeds are established
        1. Consider adding Lactulose
  15. Management: Adjunctive Measures
    1. Bronchodilators
      1. Avoid nebulizer use due to dispersion of virus
      2. Albuterol HFA Inhaler as needed
    2. Corticosteroids
      1. Dexamethasone
        1. Indicated in COVID-19 Patients on Supplemental Oxygen or Mechanical Ventilation
        2. Dosing: Dexamethasone 6 mg daily for up to 10 days
        3. https://www.covid19treatmentguidelines.nih.gov/dexamethasone/
        4. Horby (2020) N Engl J Med +PMID:32678530 [PubMed]
      2. Other Corticosteroid indications
        1. May also use Corticosteroids in those with Asthma Exacerbation or COPD exacerbation
        2. Intensivists have also used Methylprednisolone 60 mg IV daily for 3-6 days in severe ARDS
      3. Corticosteroids are not recommended early in COVID-19 course for those not with indications above
        1. Risk of increased viral shedding, worse outcomes
    3. Specific measures under investigation
      1. Convalescent Plasma
        1. Shen (2020) JAMA +PMID:32219428 [PubMed]
      2. Remdesivir
        1. Viral RNA Polymerase Inhibitor that may speed COVID-19 Recovery, but does unclear if affects mortality
        2. https://www.niaid.nih.gov/news-events/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19
        3. https://www.nejm.org/doi/full/10.1056/NEJMoa2007764
      3. Tocilizumab
        1. Anti-IL6 Monoclonal Antibody used in cancer treatment being studied in COVID-19 as of March 2020 (phase 3 trial)
          1. https://www.cancernetwork.com/news/fda-approves-phase-iii-clinical-trial-tocilizumab-covid-19-pneumonia
    4. Specific measures that do not appear effective (or for which risk is worse than benefit)
      1. Chloroquine or Hydroxychloroquine
        1. Mortality may be higher (low efficacy, adverse effects) with these drugs despite promising results in early studies
        2. Chloroquine and Hydroxychloroquine have numerous adverse effects (e.g. QTc Prolongation)
        3. https://www.medrxiv.org/content/10.1101/2020.04.16.20065920v2
        4. https://wattsupwiththat.com/2020/03/17/an-effective-treatment-for-coronavirus-covid-19-has-been-found-in-a-common-anti-malarial-drug/
      2. Azithromycin
        1. Results as of May 2020 are not promising
        2. Initial trials combined with Chloroquine showed possible improved outcomes
          1. Gautret (2020) Int J Antimicrob Agents +PMID:32205204 [PubMed]
        3. However, there is risk of Ventricular Arrhythmia related to QTc Prolongation with this combination
          1. https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-to-hydroxychloroquine-azithromycin-treatment-for-covid-19
      3. Lopinavir/Ritonavir (Kaletra, LPV/r)
        1. As of May 2020 studies demonstrate no significant efficacy, and risk of Drug Interactions
          1. Ritonavir has many Drug Interactions
          2. Cao (2020) N Engl J Med +PMID: 32187464 [PubMed]
        2. Was initially considered when Chloroquine was not available
          1. Young (2020) JAMA
          2. https://jamanetwork.com/journals/jama/fullarticle/2762688
    5. Other measures that have been used with poor evidence
      1. Zinc Supplementation
      2. Vitamin C 1.5 g IV every 6 hours
      3. Thiamine 200 mg IV every 12 hours
    6. Medications with unclear risk
      1. NSAIDs
        1. Early in COVID-19 course, some postulated risk of NSAIDs, but no current evidence of risk as of May 2020
        2. Use Acetaminophen as a first-line Analgesic, but NSAIDs are not currently contraindicated in COVID-19
      2. ACE Inhibitors and Angiotensin Receptor Blockers (ARBs)
        1. Coronavirus targets ACE-2 Receptors as an entry into cell
        2. Postulated that ACE Inhibitors might up-regulate ACE Receptors
        3. No evidence as of significant benefit or harm of these agents as of May 2020
    7. Indications for empiric Community Acquired Pneumonia treatment
      1. Imaging consistent with Pneumonia
      2. Procalcitonin >0.26 ng/ml
  16. Prognosis: Severe Cases
    1. Indicators of complications or more serious, progressive infection or death
      1. Male gender
      2. Older age (60 years and older)
      3. Comorbidity (e.g. Hypertension, Diabetes Mellitus, Cardiovascular Disease, Renal Disease, Liver Disease, COPD)
        1. Hospitalized patients: 23 to 71% have at least one comorbid condition
        2. ICU Patients: 43 to 78% have at least one comorbid condition
        3. Mortality: >94% have at least one comorbid condition
      4. Body Mass Index (BMI>30)
      5. Tobacco Abuse
        1. Smoking confers more severe case (RR 1.4)
        2. Smoking confers increased risk of ICU admission, Mechanical Ventilation and death (RR 2.4)
        3. Vardavas (2020) Tob Induc Dis 18:20 [PubMed]
      6. Immunocompromised patients
      7. Pregnancy
      8. D-Dimer >1 on admission
      9. SOFA Score high
    2. Age-Related Prognosis
      1. Age <20 years
        1. Hospitalizations: 1.6 to 2.5%
        2. ICU admissions: 0
        3. Deaths: 0
      2. Age 20-44 years
        1. Hospitalizations: 14.3 to 20.8%
        2. ICU admissions: 2.0 to 4.2%
        3. Deaths: 0.1 to 0.2%
      3. Age 45 to 54 years
        1. Hospitalizations: 21.2 to 28.3%
        2. ICU admissions: 5.4 to 10.4%
        3. Deaths: 0.5 to 0.8%
      4. Age 55 to 64 years
        1. Hospitalizations: 20.5 to 30.1%
        2. ICU admissions: 4.7 to 11.2%
        3. Deaths: 1.4 to 2.6%
      5. Age 65 to 74 years
        1. Hospitalizations: 28.6 to 43.5%
        2. ICU admissions: 8.1 to 18.8%
        3. Deaths: 2.7 to 4.9%
      6. Age 75 to 84 years
        1. Hospitalizations: 30.5 to 58.7%
        2. ICU admissions: 10.5 to 31.0%
        3. Deaths: 4.3 to 10.5%
      7. Age >85 years
        1. Hospitalizations: 31.3 to 70.3%
        2. ICU admissions: 6.3 to 29.0%
        3. Deaths: 10.4 to 27.3%
    3. References
      1. (2020) MMWR Morb Mortal Wkly Rep 69(12):343-6 [PubMed]
  17. Prognosis: Mortality
    1. Mortality (Worldwide)
      1. France: 15.3%
      2. Italy: 14.4%
      3. U.K.: 14.1%
      4. Mexico: 11.7%
      5. Sweden: 10.4%
      6. Ecuador: 8.4%
      7. Canada: 8.1%
      8. U.S.: 5.7%
      9. Johns Hopkins Coronavirus Resource Center (accessed 6/9/2020)
        1. https://coronavirus.jhu.edu/data/mortality
    2. Mortality: Cohorts
      1. By Age
        1. Age <=54 years old: <1% Mortality
        2. Age 70-79 years old: 8% Mortality
        3. Age >80 years old: 10-27% Mortality
      2. By Age in ICU
        1. Age 16 to 49 years old: 25%
        2. Age 50 to 59 years old: 41%
        3. Age 60 to 69 years old: 56%
        4. Age >70 years old: 69%
        5. (2020) MMWR Morb Mortal Wkly Rep 69(12):343-6 [PubMed]
      3. By Severity
        1. Hospitalized patients with Pneumonia have a 4-15% risk of death
        2. Acute Respiratory Distress Syndrome (ARDS) is associated with 51% mortality
        3. Intubated patients have mortality rates as high as 81%
  18. Prevention: General Measures
    1. Wearing masks (cloth or surgical masks) prevents COVID-19 transmission
      1. Wearing in indoor public spaces helps protect both the wearer and especially those around them
      2. Infectious persons may be contagious days before symptoms manifest
        1. Consider masking in any indoor space including home when virus exposure is possible
      3. Consider outdoor masks when social distancing cannot be maintained
      4. Evidence for masking as primary prevention is strong
        1. Brooks (2020) JAMA
          1. https://jamanetwork.com/journals/jama/fullarticle/2768532
        2. Hendrix (2020) MMWR Morb Mortal Wkly Rep 69:930-2 [PubMed]
    2. Vaccination
      1. Influenza Vaccine (October)
        1. Does not protect against COVID-19
        2. Reduces clinical visits for Influenza
        3. Reduces potential COVID-19 exposures (while seeking healthcare)
        4. Reduces risk of lung injury from Influenza (and possible risk for worse outcome in COVID-19)
        5. Reduces diagnostic confusion in differentiating Influenza presentations from COVID-19 presentations
  19. Prevention: Transmission
    1. Move patient to airborne infection isolation room or unit with negative airflow
    2. Personal Protection Equipment (N95 Mask, gown, Eye Protection and gloves) applied with donning and doffing
      1. https://www.youtube.com/watch?v=bG6zISnenPg
      2. Doffing is the highest risk time and should follow a careful protocol (consider assigned staff to help direct)
      3. See Donning and Doffing Personal Protection Equipment
      4. See Personal Protection Equipment
      5. See Respiratory Personal Protective Equipment (includes N95 Mask, PAPR)
    3. Hand Hygiene with soap and water (or >60% Alcohol hand cleanser)
    4. Disinfect surfaces
  20. Prevention: Social Isolation Precautions
    1. Social distancing is helps to slow COVID-19 infection spread, but it does have mental health risks
    2. Social distancing is associated with Increased rates of depressed mood, anxiety, Substance Abuse
    3. See Psychological First Aid
    4. Reduce Excessive Worry
      1. Avoid over-checking the news or social media (limit to once or twice daily)
      2. Choose reliable resources for information
    5. Perform regular Exercise
    6. Practice Relaxation Techniques
    7. Stay connected via phone and video conferencing with friends and family
    8. Patient Resources
      1. See Suicide Risk
      2. Disaster Distress Help Line
        1. https://www.redcross.org/get-help/disaster-relief-and-recovery-services/recovering-emotionally.html
    9. References
      1. (2020) Presc Lett 27(5): 25-6
  21. Prevention: Video Resources
    1. Stay at Home, Stop the Spread Video (EM:RAP)
      1. https://www.youtube.com/watch?v=Y7PMvJJztAA
    2. We're Here to Help (EM:Rap)
      1. https://www.youtube.com/watch?v=0Omxx75I8C0
  22. Resources
    1. Johns Hopkins Coronavirus Resource Center
      1. https://coronavirus.jhu.edu/
    2. EM:Rap Covid19 Update (March 31)
      1. https://www.youtube.com/watch?v=GLbKyc31XhM
    3. EM:Rap Covid19 Update (March 25)
      1. https://www.youtube.com/watch?v=e51V9M2avrw
    4. CDC COVID-19
      1. https://www.cdc.gov/coronavirus/2019-ncov/index.html
    5. COVID-19 (EM-CRIT: Internet Book of Critical Care)
      1. https://emcrit.org/ibcc/covid19/
    6. Corependium (Mason and Herbert)
      1. https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19
  23. References
    1. Reuter (2020) Crit Dec Emerg Med, Covid19 Edition, 3-13
    2. Fei Zhou (2020) Lancet , pre-publication online
      1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
    3. Levitan (2020) ACEP Now
      1. https://www.acepnow.com/article/covid-19-lessons-learned-by-an-emergency-physician-in-new-york-city/
    4. COVID-19 Ventilation: Quick Reference Guide (Bolton Critical Care Team)
      1. https://www.stemlynsblog.org/covid-19-a-primer-on-icu-care-for-the-non-intensivist-st-emlyns/

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