Chinese Expert Consensus on COVID-19 Severe Patients Treatment

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Chinese Expert Consensus on the Diagnosis and Treatment of Severely and Critically Ill Patients with Coronavirus Disease 2019

The coronavirus disease 2019 (COVID-19) has emerged as a significant global health threat, with no specifically targeted effective drug available at the time of writing. The initial symptoms of COVID-19 patients typically include fever, dry cough, and fatigue, although some patients may present with vomiting, diarrhea, and other gastrointestinal symptoms. Severe symptoms such as chest tightness, dyspnea, and respiratory distress usually appear one week later, with some patients rapidly developing acute respiratory distress syndrome (ARDS), septic shock, and potentially death. A retrospective study of critically ill COVID-19 patients reported that 67.3% presented with ARDS, 28.9% with acute kidney injury, 23.1% with heart injury, and 28.9% with abnormal liver function. The 28-day mortality rate was as high as 61.5%.

Given the novelty of COVID-19 and the limited understanding of the disease, the consensus draws on successful experiences from combating severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Clinical experts from the frontline of the COVID-19 battle conducted in-depth discussions to establish consensus on diagnosis, treatment principles, prevention of complications, discharge, and follow-up for severely and critically ill COVID-19 patients.

Diagnosis

The diagnosis of COVID-19 should refer to the “Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7).” This protocol provides comprehensive guidelines for identifying COVID-19 based on clinical symptoms, laboratory tests, and imaging findings.

Treatment

In addition to symptomatic treatment, clinicians should focus on preventing and treating complications, managing underlying conditions, preventing secondary infections, and providing timely organ function support.

Antiviral Treatment

There is currently no specific effective antiviral drug for COVID-19. The use of neuraminidase inhibitors (oseltamivir, palamivir, zanamivir, etc.) and ganciclovir is not recommended.

Glucocorticoid Therapy

The administration of systemic glucocorticoids to severely and critically ill COVID-19 patients is generally not recommended. However, methylprednisolone (0.5–2.0 mg/kg/day) should be given as early as possible for 3 to 5 days to patients with rapidly progressing conditions complicated by moderate-to-severe ARDS (partial pressure of oxygen [PaO2]/fraction of inspired oxygen [FiO2] <150 mmHg).

Antibiotic Treatment

The use of antimicrobial drugs, especially in combination with other broad-spectrum antimicrobials, is not recommended. However, second-generation cephalosporins can be used short-term to prevent bacterial infections in patients receiving glucocorticoid therapy. Third-generation cephalosporins combined with enzyme inhibitors can be used empirically in patients with bacterial co-infections.

Respiratory Support Therapy

  1. Oxygen therapy is recommended immediately for severely and critically ill COVID-19 patients.
  2. High-flow nasal oxygen (HFNO) is the first choice for patients with severe acute hypoxic respiratory failure or mild-to-moderate ARDS (150 mmHg < PaO2/FiO2 ≤ 300 mmHg), with non-invasive ventilation (NIV) as the second choice.
  3. Invasive mechanical ventilation is the first choice for patients with moderate-to-severe ARDS (PaO2/FiO2 <150 mmHg) or those who fail HFNO or NIV.

The strategy of lung protective ventilation with low tidal volumes and extracorporeal membrane oxygenation (ECMO) therapy should be considered if the partial pressure of carbon dioxide remains >50 mmHg and pH < 7.25 after increasing the respiratory rate to 35 breaths/min with adequate sedatives. Positive end-expiratory pressure (PEEP) titration is suggested to set the optimal PEEP level. Prone position ventilation should be applied for more than 12 hours per day for patients with moderate-to-severe ARDS (PaO2/FiO2 <150 mmHg) as early as possible. Sedatives and analgesics are recommended for patients receiving invasive mechanical ventilation but not as routine treatment. The closed suction pipe is suggested, and the disconnection of the ventilator requires clamping its pipe. ECMO can be used as a remedy for patients with severe ARDS.

Circulatory Support Therapy

  1. Conservative fluid therapy is recommended for ARDS patients who are sufficiently perfused.
  2. The sepsis-3 definition should be referred to identify septic shock.
  3. Patients with septic shock accompanied by hypotension or lactate ≥4 mmol/L should be supplemented with isotonic crystalloid solution rapidly within 1 hour.
  4. With sufficient rescue fluid resuscitation, vasoactive drugs should be administered to maintain the target mean arterial pressure ≥65 mmHg. Norepinephrine is the first choice for vasoactive drug therapy and can be combined with epinephrine, vasopressin, and dobutamine.

Renal Support Therapy

For patients with excessive inflammatory reactions, the use of in vitro blood purification techniques should be considered as early as possible.

Liver Support Therapy

Patients with liver failure should receive artificial liver support.

Cardiac Protective Therapy

COVID-19 patients with acute myocardial injury can be prescribed drugs that nourish the myocardium.

Nutritional Support and Other Treatments

  1. Patients should receive enteral nutrition promptly, even during the use of prone position ventilation or ECMO, and intestinal micro-ecological therapy should be given as early as possible.
  2. Human convalescent plasma containing SARS-CoV-2 antibodies can be used for patients with rapidly progressing disease or those who are severely and critically ill.
  3. Thymosin α1 can be administered to patients with low lymphocyte counts and disordered cellular immune systems. The treatment of gamma globulin should be used with caution.
  4. Ventilator-associated pneumonia, deep vein thrombosis, catheter-related bloodstream infections, stress ulcers, and intensive care unit-related complications should be prevented.
  5. Chinese patent medicine suitable for severely and critically ill patients should be chosen, referring to the “Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7).”
  6. Psychological support and psychiatric consultation should be noted.

Discharge

Discharge criteria should refer to the “Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7).”

Follow-up

Patients should be followed up at 1, 3, 6, and 12 months after discharge, and pulmonary function should be monitored.

Funding

This study was supported by grants from the United Fund of National Natural Science Foundation of China, the Scientific and Technological Innovation Leaders in Central Plains, Provincial Ministry Co-construction Project from Medical Scientific and Technological Research Program of Henan Province of China, the “51282” Project Leaders of Scientific and Technological Innovative Talents from Health and Family Planning Commission in Henan Province of China, Zhengzhou City Science and Technology People-Benefit Project of Henan Province of China, Subject of Major National Science and Technology, and Key Project of Novel Coronavirus Pneumonia Funded by Science and Technology Department of Hubei Province.

Conflicts of Interest

None.

doi.org/10.1097/CM9.0000000000001264

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