Clinical Pearls & Morning Reports
Patients with severe coronavirus disease 2019 (Covid-19) may become critically ill with acute respiratory distress syndrome, which typically begins approximately 1 week after the onset of symptoms. Read the NEJM Clinical Practice Article here.
Q: Who is most at risk for severe Covid-19?
A: Healthy persons of any age may become critically ill with Covid-19. However, age is the most important risk factor for death or critical illness, and the risk increases with each additional decade. People with chronic health conditions such as cardiovascular disease, diabetes mellitus, immunosuppression, and obesity are more likely to become critically ill from Covid-19. Severe disease is more common among men than among women. The risk is also increased among certain racial and ethnic groups such Black and Hispanic persons in the United States.
Q: Does dexamethasone have a role in the treatment of patients with severe Covid-19?
A: A large, randomized clinical trial involving more than 6400 hospitalized patients with Covid-19 showed that dexamethasone significantly reduced 30-day mortality (17% reduction); benefit was limited to patients who required oxygen supplementation and appeared greater in patients receiving mechanical ventilation. Consequently, dexamethasone (or potentially other glucocorticoids) is now considered the standard of care for patients with severe Covid-19.
A: Data from a randomized, placebo-controlled trial involving more than 1000 patients with severe Covid-19 showed that the antiviral agent remdesivir reduced time to clinical recovery; the benefit appeared greatest in patients who were receiving supplemental oxygen but were not intubated. The 29-day mortality in that trial was 11.4% with remdesivir and 15.2% with placebo (hazard ratio for death, 0.73; 95% confidence interval, 0.52 to 1.03). These data support the Food and Drug Administration (FDA) approval of remdesivir for the treatment of hospitalized patients with Covid-19 in October 2020. Recent preliminary results of a large, multinational, open-label, randomized trial did not show a reduction in in-hospital mortality with use of remdesivir. The combination of dexamethasone and remdesivir is increasingly used clinically, but its benefit has not been shown in randomized clinical trials.
A: It is unclear whether Covid-19 is associated with a distinct form of acute respiratory distress syndrome (ARDS) that would benefit from a new strategy of mechanical ventilation. However, most autopsies performed on patients with severe Covid-19 reveal the presence of diffuse alveolar damage, which is the hallmark of ARDS. If there are no contraindications, patients should receive standard thromboprophylaxis (e.g., subcutaneous low-molecular-weight heparin). Some case series of patients with severe Covid-19 have shown clinically significant thrombosis despite the use of thromboprophylaxis. However, the benefits and risks of the routine use of more intense prophylactic anticoagulation in patients are unknown. Having awake patients turn to the prone position while they breathe high concentrations of supplemental oxygen may improve oxygenation in patients with severe Covid-19. This approach is supported by data from prospective cohorts describing its use in nonintubated patients with severe hypoxemia. However, whether prone positioning can prevent intubation in patients with severe Covid-19 is unclear.