WHO: Interim guidelines for the management of severe acute respiratory illness caused by novel coronavirus

03 Mar, 2020
The WHO has drafted a new set of interim guidelines for the management of patients with severe acute respiratory illness (SARI) caused by novel coronavirus (nCoV). It is not meant to replace clinical judgment or specialist consultation but to strengthen clinical management of these patients and provide up-to-date guidance. The guidelines address multiple points related to the detection and management of patients with SARI.

  1. Recognition and sorting of all patients at the first point of contact with the healthcare system (e.g. Emergency Dept.)
  2. Recognize that nCoV is the possible etiology for SARI
  3. Patients should be triaged, and emergency treatment should start basis the disease severity (mild, moderate, or severe)
Immediate implementation of appropriate prevention and control (IPC) measures:
  1. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin.
  2. Other precautions include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.
Early supportive therapy and monitoring:
  1. Supplemental oxygen therapy should be given immediately to patients with SARI and respiratory distress, hypoxemia, or shock.
  2. If there’s no evidence of shock in patients with SARI, use conservative fluid management.
  3. Antimicrobials should be given to all patients with SARI to treat all likely pathogens causing SARI. Antimicrobials should be given within one hour of initial patient assessment for patients with sepsis.
  4. Do NOT give routine corticosteroids for treatment of viral pneumonia outside of clinical trials unless indicated for another reason.
  5. Early communication with patient and family is key for successful management.
Collection of specimens for laboratory diagnosis:
  1. Blood cultures for bacteria that cause pneumonia and sepsis should be collected, ideally, before microbial therapy. But DO NOT delay the antimicrobial therapy to collect blood cultures.
  2. Specimens should be collected from both upper respiratory tract (URT) and lower respiratory tract (LRT) for nCoV testing via RT-PCR.
  3. Serology as a diagnostic procedure is recommended only when RT-PCR is NOT available.
Management of hypoxemic respiratory failure and ARDS:
  1. If a patient with respiratory distress is failing standard oxygen therapy, it should be recognized as hypoxemic respiratory failure.
  2. High-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) should only be used in selected patients with hypoxemic respiratory failure. 
  3. In patients with severe ARDS, prone ventilation for >12 hours per day is recommended
  4. For ARDS patients without tissue hypoperfusion, use a conservative fluid management strategy.
  5. In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested.
  6. Consider referral of patients with refractory hypoxemia despite lung protective ventilation if access if available to extracorporeal life support.
  7. Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection from the ventilation is required.
Specific anti-Novel-CoV treatments and clinical research:
  1. There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or confirmed nCoV.
  2. Unlicensed treatments should be administered only by referring to ethically approved clinical trials or the Monitored Emergency Use of Unregistered Interventions Framework (MEURI), with strict monitoring.
Special considerations for pregnant patients:
  1. Pregnant women should be treated as outlined above, keeping in mind the physiologic adaptations of pregnancy.
  2. Investigational therapeutic agents might be used, but only after careful risk-benefit analysis based on potential benefits for mother and safety to fetus, after consulting an obstetric specialist and ethics committee.

Source: docquity.com