WHO: Interim guidelines for the management of severe acute respiratory illness caused by novel coronavirus

The WHO has drafted a new set of interim guidelines for the management of patients with severe acute respiratory illness (SARI) caused by novel coronavirus (nCoV). It is not meant to replace clinical judgment or specialist consultation but to strengthen clinical management of these patients and provide up-to-date guidance.

The guidelines address multiple points related to the detection and management of patients with SARI.

1.Triage: 

  1. Recognition and sorting of all patients at the first point of contact with the healthcare system (e.g. Emergency Dept.)
  2. Recognize that nCoV is the possible etiology for SARI, which is based on the conditions outlined in Table 1.
  3. Patients should be triaged, and emergency treatment should start basis the disease severity (mild, moderate, or severe)

Table 1 Definitions of patients with SARI, suspected of 2019-nCoV infection

2. Immediate implementation of appropriate prevention and control (IPC) measures

  1. Standard precautions include hand hygiene; use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin.
  2. Other precautions include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.
  3. The details of infection prevention measures are outlined in Table 2.

Table 2 Clinical syndromes associated with 2019-nCoV infection

3. Early supportive therapy and monitoring

  1. Supplemental oxygen therapy should be given immediately to patients with SARI and respiratory distress, hypoxemia, or shock.
  2. If there’s no evidence of shock in patients with SARI, use conservative fluid management.
  3. Antimicrobials should be given to all patients with SARI to treat all likely pathogens causing SARI. Antimicrobials should be given within one hour of initial patient assessment for patients with sepsis.
  4. Do NOT give routine corticosteroids for treatment of viral pneumonia outside of clinical trials unless indicated for another reason.
  5. Early communication with patient and family is key for successful management.

4. Collection of specimens for laboratory diagnosis

  1. Blood cultures for bacteria that cause pneumonia and sepsis should be collected, ideally, before microbial therapy. But DO NOT delay the antimicrobial therapy to collect blood cultures.
  2. Specimens should be collected from both upper respiratory tract (URT) and lower respiratory tract (LRT) for nCoV testing via RT-PCR.
  3. Serology as a diagnostic procedure is recommended only when RT-PCR is NOT available.

5. Management of hypoxemic respiratory failure and ARDS

  1. If a patient with respiratory distress is failing standard oxygen therapy, it should be recognized as hypoxemic respiratory failure.
  2. High-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) should only be used in selected patients with hypoxemic respiratory failure.
  3. In patients with severe ARDS, prone ventilation for >12 hours per day is recommended
  4. For ARDS patients without tissue hypoperfusion, use a conservative fluid management strategy.
  5. In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested.
  6. Consider referral of patients with refractory hypoxemia despite lung protective ventilation if access if available to extracorporeal life support.
  7. Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection from the ventilation is required.

6. Management of septic shock

  1. Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥65 mmHg AND lactate is ≥2 mmol/L, in absence of hypovolemia.
  2. Recognize septic shock in children with any hypotension or 2-3 of the following:
    1. altered mental state
    2. tachycardia or bradycardia
    3. prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses
    4. tachypnea
    5. mottled skin or petechial or purpuric rash
    6. increased lactate
    7. oliguria
    8. hyperthermia or hypothermia
  3. In resuscitation from septic shock in adults, give at least 30 ml/kg of isotonic crystalloid in adults in the first 3 hours. In resuscitation from septic shock in children, give 20 ml/kg as a rapid bolus and up to 40-60 ml/kg in the first 1 hr.
  4. Do NOT use hypotonic crystalloids, starches, or gelatins for resuscitation.
  5. If there is no response to fluid loading and signs of volume overload appear then reduce or discontinue fluid administration to avoid chances of respiratory failure.
  6. Administer vasopressors when shock persists during or after fluid resuscitation.
  7. Vasopressors can be given through a peripheral IV if central venous catheters are not available.
  8. An inotrope (e.g. dobutamine) could be used if signs of poor perfusion and cardiac dysfunction persist, despite achieving MAP target with fluids and vasopressors

7. Prevention of complications

  1. Refer to Table 3 for the details

Table 3 Prevention of complications

8. Specific anti-Novel-CoV treatments and clinical research

  1. There is no current evidence from RCTs to recommend any specific anti-nCoV treatment for patients with suspected or confirmed nCoV.
  2. Unlicensed treatments should be administered only by referring to ethically approved clinical trials or the Monitored Emergency Use of Unregistered Interventions Framework (MEURI), with strict monitoring.

9. Special considerations for pregnant patients

  1. Pregnant women should be treated as outlined above, keeping in mind the physiologic adaptations of pregnancy.
  2. Investigational therapeutic agents might be used, but only after careful risk-benefit analysis based on potential benefits for mother and safety to fetus, after consulting an obstetric specialist and ethics committee.