Hospital Management of COVID-19

Inpatient Management of COVID-19 Respiratory Failure

For inpatient treatment of COVID-19 pneumonia with acute respiratory failure (aka, people with a positive COVID-19 test who need oxygen to keep their SPO2 > 92%).

Oxygen therapy levels

Titrate oxygen for SPO2 > 92%

Oxygen delivery modalities, stepwise:

• Simple face-mask (avoid)

• Non-Rebreather (face-mask with bag, also avoid)

• Nasal cannula

• Venturi Mask / Oxymask

• High-Flow Nasal Cannula

• BiPAP

• Intubation & Ventilator

Non-medication adjuncts

• Incentive spirometry (IS) at bedside (how to use IS)

• Encourage patients to "self-prone" by changing position every 30 minutes, choosing between sitting up, left side, back, right side, stomach.  (Note: Qian et. al 2022 suggests that self-proning in non-intubated patients may not confer benefit.)

For all patients requiring oxygen (respiratory failure)

• Dexamethasone 6 mg IV or PO q24 hours for 10 days

• Remdesivir 200 mg IV x 1, then 100mg IV q24 hours for 5 days, or

For high risk patients, or anybody that acutely worsens

It is not yet clear whether baricitinib or tocilizumab is superior. Choice depends mostly on availability and institutional practice.

• An anti-inflammatory medication, either:

• Baricitinib 4 mg PO for 14 days, or

• Tocilizumab 8mg/kg (weight >= 30kg) or 12mg/kg (weight < 30kg) IV infusion x 1 (max dose 800 mg)

If bacterial pneumonia suspected

2-3% of COVID-19 pneumonia patients also develop bacterial pneumonia.

• Ceftriaxone 2 gm IV q24 hours x 5 days,

• Plus pick one:

• Usually: Azithromycin 500 mg IV q24 hours x 5 days, or

• If concern for MRSA: Doxycycline 200 mg IV x 1, then 100 mg IV q12 hours for 10 days

For symptom relief

• Tessalon perles (aka benzonatate) PRN cough

• Guaifenesin (with or without codeine) PRN cough

• Ipratropium-albuterol nebulizer treatments PRN shortness of breath

• Acetaminophen PRN pain/fever/headache

DVT prophylaxis

• Pick your favorite prophylaxis:

• Lovenox 30-40 mg SQ q24 hours (normal prophylactic dose, adjusted for renal function if necessary), or

• If kidney injury: Heparin 10K units q8-12 hours