By: Dr. YOTIN. CHINVARUN. M.D. Ph.D.
Treating COVID-19: Tips and Practical point for Physicians
From Experienced of Suraj Saggar, DO, chief of infectious diseases at Holy Name Medical Center in Teaneck, New Jersey
- Testing Unreliable: slow turnaround for tests, paired with low sensitivity as documented in Chinese data, makes them less useful.
“There were a lot of false negatives [in China], especially early on in asymptomatic patients, The Chinese realized early on that the sensitivity wasn’t good, he said, so they would add on a CT scan to diagnose the disease. But that’s not practical because the machines have to be shut down for cleaning after each case.
“Be better to rely on the symptom “triad” — fever, cough, and shortness of breath — to guide diagnosis. They also use chest X-rays and other lab markers — leukopenia, lymphopenia, monocytosis, transaminitis, elevated C-reactive protein, normal procalcitonin — to determine whether a patient has COVID-19. Elevated d-dimer may be particularly predictive of who might have respiratory failure,
- COVID-19 symptoms can be very varied, Gastrointestinal symptoms, for instance, can precede pulmonary symptoms, therefore patient can be initially present alike food-related illness
- About 80% of patients are male and unexpected young age of patients with more severe disease in US
- Other trends, observing that central or morbid obesity seemed to indicate worse disease course, including the need for mechanical ventilation
“Obesity could be an issue because if they’re more likely to have sleep apnea, they may aspirate the virus and it makes it into the lungs,”
- Disease course is still unpredictable, in some cases, patients seem to start improving, but then take a turn for the worse
- Patients go from 2-, 3-, 4-liter nasal cannula to 50% venturi mask to high-flow oxygenation to 100% non-rebreather mask to BiPAP, then may have to intubate “That usually happens within 24 hours. And it’s a prolonged course of mechanical ventilation, more than 5 days.”
- Other Treatments
- Many of the severe cases have been treated with the antiviral lopinavir/ritonavir (Kaletra), but not seeing great results with Kaletra New England Journal of Medicine report published Wednesday showed it was ineffective in a randomized trial.
- Chloroquine and zinc plus vitamin C,” can be helpful for its anti-inflammatory properties
- investigational antiviral remdesivir under compassionate use protocols. While getting the drug has been relatively quick, there’s a narrow window for using it — patients need to be “sick but not too sick, That means they have to be intubated or on extra corporeal membrane oxygenation (ECMO), but they can’t have multi-organ dysfunction.
- There’s been some talk about using the flu treatment oseltamivir (Tamiflu), and for those who develop acute respiratory distress syndrome due to cytokine storm, the anti-IL-6 drug tocilizumab (Actemra) may be considered.
- Prone ventilation and using fluticasone (Flovent) or a phosphodiesterase-4 inhibitor to dilate the lungs for better aeration are also under consideration
- To be cautious about using NSAIDs because there’s been some suggestion that these may prompt overexpression of ACE2 receptors, which the virus uses to enter the cell.
Reference
Medpage Today, by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage March 19, 2020