Introduction
Management of patients with SARS-CoV-2 infections
The current epidemiological situation
General facts on COVID-19
Symptoms | Positively tested people (including mild cases) | Hospitalized COVID-19 patients |
---|---|---|
Fever/chills | 49% | 85% |
Cough | 24% | 86% |
Shortness of breath | – | 80% |
Myalgia | – | 34% |
Diarrhea | 2% | 27% |
Nausea/vomiting | – | 24% |
Sore throat | 12% | 18% |
Headache | – | 16% |
Nasal congestion, rhinorrhea | 4% | 16% |
Chest pain | – | 15% |
Abdominal pain | – | 8% |
Fatigue | 8% | – |
Aching | 7% | – |
Hospitalization and mortality risk for COVID-19 and community-acquired pneumonia due to other pathogens
Hospital mortality | ICU mortality | |
---|---|---|
12.9–14.1% | 17.0–29.5% | |
8.0–12.0% | 17.5–26.0% | |
3.9–18.5% | 21.6% | |
14.8% | 22.0% | |
12.6% | 17.1–41.2% | |
COVID-19 | ||
10.7–21.9% | 61.5% | |
USA (New York)b [37] | 21.0% | 78.0% |
Europe (ECDC) [2] | 14% | – |
United Kingdoma [26] | – | 34.8–46.8% |
Spaina [38] | – | 29.2% |
Italy (Lombardy)a [39] | – | 25.6% |
Comorbidities of deceased patients | COVID-19 (%) | Other CAP pathogens (%) |
---|---|---|
Arterial hypertension | 40–75 | 54 |
Diabetes | 20–31 | 31 |
Heart diseases | 23–49 | 38 |
Neurologic disorders | 13 | 16–19 |
Carcinomas | 2–18 | 28 |
Chronic renal insufficiency | 23 | 13–27 |
Chronic lung diseases | 8–19 | 6–24 |
Dementia | 18 | 28 |
SARS-CoV-2 in children
Epidemiological outlook
Management of SARS-CoV-2 pneumonia
Basic management of SARS-CoV-2 CAP
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Early diagnosis of CAP, possibly simultaneously decompensated underlying diseases and the recognition of life-threatening situations
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Start of CAP therapy without delay (including the treatment of respiratory insufficiency, hemodynamic instability, decompensated underlying diseases and, if indicated, anti-infective therapy)
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Triage according to the clinical findings (outpatient vs. inpatient vs. intensive care treatment)
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Definition of appropriate treatment goals and avoidance of futile treatment in palliative patients already suffering from severe underlying diseases (see below)
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From the outset, consequent adherence to strict hygiene measures for personal protection and the avoidance of nosocomial infections
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Prevention of new infections
Diagnostics
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Outpatients who are not seriously ill should contact the established contact points by telephone and seek information and advice on the current procedure (Fig. 1).
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A chest CT scan without contrast agent should be performed in patients in the emergency department or already hospitalized if a lower respiratory tract infection is suspectedANDthe chest x‑ray is unremarkable (or difficult to interpret)ANDthe rapid diagnostic tests for common infections (Influenza/RSV/SARS-CoV‑2 PCR, Pneumococcus/Legionella urine antigen test) are negativeAND
Specific SARS-CoV-2 CAP therapy
Systemic steroids
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Severe COPD exacerbation: 0.5 mg prednisolone/kg/day for 5–7 days, then stop.
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Severe asthma exacerbation: 0.5 mg prednisolone/kg/day for a maximum of 7 days, then slowly tapering over a further 7 days.
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In the course of svCAP, systemic steroids may be considered in suspected individual cases of organizing pneumonia, postpneumonic interstitial pneumonia, hemophagocytic lymphohistiocytosis, or exacerbation of pre-existing pulmonary fibrosis.
Respiratory intensive care
Aerosol therapy
Hospitalized COVID-19 patients with sleep-related breathing disorders
Bronchoscopy in COVID-19 patients
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Extremely restrictive indications for a bronchoscopy.
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Primary use of other sensitive diagnostic procedures (e.g. obtaining tracheal secretions via a closed suction system for microbiological testing including SARS-CoV‑2 PCR).
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Bronchoscopy is indicated in emergency situations (e.g. life-threatening hemoptoe, high-grade airway stenosis, or foreign body aspiration), or if an alternative diagnosis can be verified, which would lead to a significant change in therapeutic management.
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Reduction of staff (bronchoscopist, bronchoscopy assistance, if necessary an anesthesia team) to a core team. No students, basic or advanced trainees in the bronchoscopy suite.
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Strict personal protection for the entire team (disposable protective gown, disposable gloves, FFP3 mask, protective glasses/visor, hair protection). Strict attention to correctly putting on and taking off protective clothing.
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If justifiable, rigid bronchoscopies with jet ventilation should not be performed; however, should a rigid bronchoscopy be unavoidable, it should be performed in an intubated patient with conventional ventilation and reduced aerosol escape, e.g. using a FLUVOG attachment (KARL STORZ SE & Co. KG, Tuttlingen, Germany).
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Bronchial lavage should be performed as fractionated procedure (10 ml NaCl 0.9% for each fraction; to reduce the transmission risk, the suction device should be clamped after sampling or before disconnection).
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Bronchoscopes are to be cleaned and disinfected in a validated manner; there is no evidence that these processes have to be changed for SARS-CoV‑2.
Therapeutic goals, treatment limitations and withdrawal of treatment in COVID-19 patients
General management of patients with chronic lung disease during the COVID-19 pandemic
Measures for the prevention of COVID-19 and/or severe courses of the illness (recommendations for patients with underlying diseases)
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Adherence to currently recommended hygiene measures and contact restrictions for chronically ill patients.
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Early contact with the healthcare system, if signs and symptoms of infection develop (Fig. 1).
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Continuation of the current therapy of the chronic lung disease (no discontinuation of medication for fear of SARS-CoV‑2, consultation with the attending physician).
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Immediate cessation of nicotine consumption, since smoking significantly increases the mortality risk of COVID-19 patients [95].
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Physical activity to prevent muscular deconditioning.
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Completion of the vaccination status with pneumococcal vaccine at the next opportunity.
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Influenza vaccination from November 2020.
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Age >65 years and a severe lung disease of any kind
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Age ≤65 years with
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pO2 <65 mm Hg at room air or
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long-term oxygen therapy (LTOT) or
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FEV1 <70% of reference value or
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FVC <70% of reference value or
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diffusion capacity <70% of reference value or
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cystic fibrosis or
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active cancer or
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systemic immunosuppressive therapy or congenital immunodeficiency.
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Influenza vaccination
Asthma and COPD
Asthma
COPD
Asthma and COPD patients with probable or confirmed SARS-CoV-2 infection
Lung cancer
Cystic fibrosis (CF)
Interstitial lung diseases
Pulmonary hypertension
Pulmonary rehabilitation and smoking cessation therapy
Sleep-associated breathing disorders
Transplantation
Cardiorespiratory physiotherapy
Physiotherapeutic interventions with a potentially high virus exposure
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Inhalation training, secretion-removing techniques and sputum induction
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Manual and mechanical cough assist
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Oxygen therapy (also with nasal cannula)
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Intermittent positive pressure breathing (IPPB) and NIV
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Airway suctioning
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Mobilization and training
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Care for tracheotomised patients
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Inspiratory and expiratory muscle training
Aerosol therapy
General rules for physiotherapeutic interventions in intubated/tracheotomized patients with COVID-19 or suspected COVID-19
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Suctioning in intubated/tracheotomized patients should only be performed with a closed suction system.
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Disconnection of ventilated patients from the ventilator should generally be avoided; if absolutely necessary it should be carried out with a clamped tube and deactivated ventilator.
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Deflation of the cuff of a tracheal cannula and cleaning of the inner cannula potentially create the risk of airborne virus transmission.
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To minimize the risk of virus transmission, inspiratory muscle training and the use of speaking valves with tracheal cannulas should only be carried out after the acute infection has subsided.
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Obligatory use of personal protection equipment (mask, goggles, long-sleeved protective coats; gloves; staff with beards should remove facial hair to enable a proper fit of the face mask; for interventions that increase the airborne virus load, hair protection has to be worn).
General additional recommendations for chest physiotherapy in non-intubated patients
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Obligatory use of personal protection equipment (see above)
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Adherence to cough etiquette (applies to staff and patients):
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During coughing and expectoration avert the head.
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Secure the secretions in a tissue or a container and dispose of it immediately; subsequent obligatory hand disinfection.
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For intentional coughing maneuvers: minimum distance of 2 m and/or moving out of the likely path of dispersion.
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Physiotherapeutic interventions only on request/after consultation with the responsible physician.
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In case of an essential physiotherapeutic intervention with a potential risk of virus transmission:
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Completion in a single-bed room with the doors closed.
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Minimum staffing with all those present wearing personal protective equipment.
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Use of one-way products.
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No sputum induction.
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No manual hyperinflation, if a mechanical option is available.
Respiratory nursing
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Consistent adherence to personal hygiene measures:
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Frequent hand washing
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The avoidance of contact with eyes, nose and mouth
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Sneezing and coughing preferably into a handkerchief, which should immediately be disposed of
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A minimum distance of 2 m to other people
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Hand hygiene in all health care areas
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Organizational precautionary measures:
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Reduction and control of patient flow in order to prevent transmission from patient to patient.
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Provision of infected patients with mouth and nose protection if the patient’s state of health permits.
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Spatial distancing of suspected patients from other people, ideally in an isolation room with a vacuum lock and its own hygiene facilities.
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Reduction of patient transport to an absolute minimum and the provision of the transport staff with advance information.
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Reduction of social contacts (visitors in the hospital) by an increase in telecommunication, limitations of the number of visitors and the duration of each visit, as well as instruction of visitors regarding hygiene measures.
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Information, education and instruction of the relevant staff on protective measures and monitoring their own health status.
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Reduction of inward and outward transfers for the treatment and care of infected patients by cohorting them under certain circumstances and planning and merging their care measures.
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Disinfection and cleaning of patient-near, contaminated, or probably contaminated surfaces and used medical devices with disinfectants possessing at least limited viricidal effectiveness.
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Personal safety measures/personal protective equipment:
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The choice of appropriate personal protective equipment depends on the nature and extent of patient care.
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Due to the current worldwide demand for personal protective equipment, the available products should only be used in a resource-protective manner (reuse in compliance with the respective manufacturer’s specifications, ensuring correct interim storage).
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Putting on and taking off personal protective equipment should be practiced regularly; for COVID-19 patients only trained staff should be deployed.
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In completely isolated areas (e.g. an entire hospital ward) it should be ensured that the shifts of nursing staff, who constantly wear protective equipment, do not exceed 3–4 h before a break can be taken, in order to prevent pressure-related injuries from the protective equipment. Hydrocolloids have proved to be effective for skin protection.
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Hand disinfection using disinfectant agents with at least limited viricidal capacity before protective equipment is put on, gloves are removed, and prior to leaving the room, as well as in accordance with other standard hand hygiene procedures.
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For care measures involving aerosol production, masks should be worn that stop at least 95% of all particles with a diameter of >0.3 µm. This corresponds to the FFP2 class of the respiratory mask classification system used in Europe.
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The minimum personal protective equipment for the direct care of COVID-19 patients, or patients suspected of being SARS-CoV‑2 positive, consists of FFP2 masks, safety goggles or a face shield, a long-sleeved water-repellent protective gown and disposable gloves.
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