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Inpatient COVID-19 Management
A 3-Pronged Approach to Inpatient Management of COVID-19

Released: March 23, 2023

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Key Takeaways
  • Management of hospitalized patients with COVID-19 is complex and requires a multifaceted approach.
  • Supportive care measures such as oxygen support, glycemic control, and anticoagulation should be maximized.
  • Appropriate stratification of disease severity and subsequent appropriate use of antivirals during the earlier viral replication phase and immunomodulators during the late inflammatory phase are essential to improve patient outcomes.

In my practice as a pulmonologist and critical care physician, I have found it helpful to take a 3 pronged approach to management of hospitalized patients with COVID-19. This includes optimizing supportive care measures, employing antiviral therapy when in the early viral replication phase of the disease, and appropriately using immunomodulating therapies during the later inflammatory phase of the disease. Here I will review important points in each of these areas.

Supportive Care Measures
Because a patient’s respiratory status often dictates how we stratify severity of illness and subsequent treatment, it is important to understand and optimize support as much as possible. We want to put everyone on the lowest possible oxygen support that they may need to maintain saturations of at least 92%, but patients with COVID-19 and acute respiratory distress syndrome may progress rapidly despite our interventions. If patients require high-flow nasal cannula, noninvasive ventilation (eg, BiPAP), or invasive ventilation, they require a higher level of ICU care. We should be cautious about use of BiPAP in this population because of a possibility of increased mortality. Consider transitioning these patients directly from high-flow nasal cannula to invasive mechanical ventilation.

Another important caveat of supportive care is glycemic control, particularly in patients receiving dexamethasone. We generally target blood glucose ranging from 140-180 mg/dL using sliding scale insulin or perhaps longer-acting insulin, when necessary. On the ICU side, we have a low threshold to initiate an insulin drip to keep blood glucose in this range. There is a delicate balance between hypoglycemia and hyperglycemia. To avoid these, it is particularly important to check glucose measurements at appropriate times, and it may be necessary to switch from a mealtime glucose check to a regular 4- to 6-hour interval if transitioning into the ICU. Many patients receiving dexamethasone will require scheduled insulin. 

Finally, an emerging area of interest in COVID-19 management is mitigating the risk of thrombosis. Mechanistically, this can occur because of the virus attaching to the endothelial lining of blood vessels, activating a downstream inflammatory cascade and clot formation. All patients requiring hospitalization should receive prophylactic anticoagulation unless otherwise contraindicated. Regular monitoring of inflammatory markers helps to determine when a clot may be present and a switch from prophylactic to therapeutic anticoagulation is warranted. Paradoxically, there is a higher risk of bleed in critically ill patients who are receiving steroids, so use of anticoagulation should be monitored closely. 

Early Viral Replication Phase: Maximize Antiviral Therapies
Next, it is important to understand treatment of acute COVID-19 itself. As mentioned, baseline supplemental oxygen requirements direct the choice of therapy. Remdesivir is an antiviral agent that has been approved by the FDA for treatment of COVID-19. In nonhospitalized patients with mild to moderate COVID-19 who are at high risk of progressing to severe disease, remdesivir should be started within 7 days of symptom onset and administered for 3 days. Hospitalized patients should receive remdesivir for 5 days or until hospital discharge, whichever comes first.

In patients requiring low-flow or high-flow oxygen (regardless of risk factors), remdesivir also is recommended. Of importance, remdesivir is most effective early in the disease process (during viral replication) and should be given within 7 days of symptom onset. Although there is no clear evidence of its efficacy in patients receiving invasive mechanical ventilation or extracorporeal membrane oxygenation, the studies may not have been sufficiently powered to analyze this.

Late Inflammatory Phase: When to Use Immunomodulating Therapies
COVID-19 is associated with diffuse lung damage due to a hyperinflammatory host immune response that typically occurs later in the disease process. Dexamethasone has demonstrated mortality benefit in patients with COVID-19 who are requiring supplemental oxygen—but also increased mortality in patients not requiring supplemental oxygen. Dexamethasone should be added to remdesivir in patients requiring supplemental oxygen.

In patients requiring high-flow nasal cannula or noninvasive ventilation, systemic inflammation is the primary driver of hypoxemia, and a second immunomodulator should be added to dexamethasone. The available options include oral baricitinib or IV tocilizumab. These also should be considered in patients with rapidly progressing supplemental oxygen requirements and/or inflammatory markers. Recent data show that baricitinib may have a better safety profile than tocilizumab. The combination of dexamethasone plus a second immunomodulating agent may increase the risk of secondary infections, so patients should be monitored closely.

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