Management of Inpatient COVID-19 Patients
Stratification and Treatment
- The European Respiratory Society recommends administering dexamethasone 6 mg daily for up to 10 days to hospitalized COVID-19 patients requiring oxygen or ventilatory support, and providing prophylactic anticoagulation, while not using corticosteroids in patients not requiring supplemental oxygen 1, 2
- For patients not requiring supplemental oxygen, the European Respiratory Society recommends against administering corticosteroids, as this provides no mortality benefit and causes harm, and to provide prophylactic-dose anticoagulation, such as low molecular weight heparin, for all hospitalized COVID-19 patients regardless of oxygen requirement 1, 2, 3
- The European Respiratory Society suggests monitoring oxygen saturation at least twice daily, with a target SpO2 no higher than 96% if supplemental oxygen becomes necessary, and monitoring respiratory rate at least twice daily, as this is often the earliest sign of deterioration before oxygen desaturation occurs 2
- For patients requiring supplemental oxygen, the European Respiratory Society recommends initiating dexamethasone 6 mg daily immediately upon oxygen requirement for up to 10 days, which reduces mortality by 3% absolute risk reduction, and continuing prophylactic anticoagulation 1, 2, 3, 4
- The European Respiratory Society suggests considering IL-6 receptor antagonist monoclonal antibody therapy, such as tocilizumab or sarilumab, for patients with evidence of COVID-19-related inflammation despite corticosteroids 1, 4, 5
Therapies to Avoid
- The European Respiratory Society strongly recommends against using hydroxychloroquine in all COVID-19 patients 1, 3, 4
- The European Respiratory Society recommends against using azithromycin unless documented bacterial coinfection exists 1, 2, 3, 4
- The European Respiratory Society strongly recommends against using lopinavir-ritonavir 1, 3, 4
- The European Respiratory Society recommends against using colchicine in hospitalized patients 1, 4
- The European Respiratory Society recommends against using interferon-β in hospitalized patients 1, 3, 4
- The European Respiratory Society recommends against using routine antibiotics unless there is clinical suspicion of bacterial infection 3
Critical Care Considerations
- The European Respiratory Society suggests considering remdesivir for hospitalized COVID-19 patients, although they made no formal recommendation for non-invasively ventilated patients and suggest against its use in invasively ventilated patients 1, 4
- The European Respiratory Society recommends considering adding a second immunosuppressant, such as IL-6 antagonist, IL-1 antagonist, or JAK inhibitor, if worsening occurs despite dexamethasone and COVID-19-related inflammation is present 5
Common Pitfalls to Avoid
- The European Respiratory Society recommends not delaying corticosteroid therapy in patients requiring oxygen, as mortality benefit is time-sensitive 2, 3
- The European Respiratory Society recommends not giving corticosteroids to non-hypoxic patients, as this causes harm without benefit 1, 2, 3
- The European Respiratory Society recommends not delaying recognition of deterioration, as respiratory rate elevation and increased work of breathing often precede oxygen desaturation 2
- The European Respiratory Society recommends not delaying intubation when non-invasive respiratory support fails or signs of exhaustion appear 3
- The European Respiratory Society recommends not overlooking anticoagulation in all hospitalized patients 2, 3