COVID-19: Guidelines and Statements
Access the latest national guidelines and statements related to the management of patients with COVID-19 and the delivery of critical care during a pandemic.
Recent Releases:
American College of CHEST Physicians
May 1, 2020
Recommendations are pertinent to the performance of bronchoscopy in patients with confirmed or suspected COVID-19. The panel suggests that:
- Health-care workers in the procedure and recovery rooms should use either an N95 respirator or a powered air purifying respirator in addition to face shield, gown, and gloves. N95 respirators should be worn when performing bronchoscopy in asymptomatic patients from an area where community spread of COVID-19 is present.
- In the setting of severe or progressive disease requiring endotracheal intubation, endotracheal aspirates or bronchoscopy with BAL can be performed if the nasopharyngeal swab is negative and additional specimen is needed to rule in COVID-19 or for confirming other diagnoses that will change management.
- Testing for COVID-19 should be performed prior to performing bronchoscopy in asymptomatic patients from an area where community spread of COVID-19 is present. Enhanced personal protective equipment should be used even if the testing results are negative. Nonemergent bronchoscopies should be postponed if patients test positive.
- Bronchoscopy should be performed in a timely and safe manner when it’s indicated to diagnose, stage, or characterize a known or suspected lung cancer in an area where community transmission of COVID-19 is present.
- In patients who recovered from COVID-19 and need a bronchoscopy, the timing of the procedure should be determined based on the indication for the procedure, the severity of the COVID-19 infection, and time from symptom resolution. Waiting at least 30 days from resolution of symptoms with two negative nasopharyngeal swab SARS-CoV-2 RNA tests collected at least 24 hours apart was considered reasonable.
American College of CHEST Physicians
April 23, 2020
These guidelines address the management of patients in lung cancer screening programs during the COVID-19 pandemic. The expert panel report makes recommendations that seek to minimize risk to patients while balancing the potential benefits of a lung cancer screening program.
- The initiation of lung cancer screening for individual patients should be delayed.
- Annual screening for patients already enrolled in a lung cancer screening program with Lung-RADS 1-2 on prior CT who are due for follow-up imaging can have their surveillance CT scan delayed.
- Annual screening for patients with previously identified pulmonary nodules who have low probability of cancer or indolent cancer, due for follow-up imaging, can have their surveillance CT scan delayed for 3-6 months (Lung-RADS 3-4 with a low estimated probability of malignancy).
- In a patient with a Lung-RADS 4 nodule with an estimated probability of malignancy that is 65-85%, it is acceptable to perform a PET scan and/or nonsurgical biopsy to ensure there is a need to proceed to treatment.
- In a patient with a Lung-RADS 4 nodule with an estimated probability of malignancy > 85%, it is acceptable to avoid further diagnostic testing and proceed to surgical resection or stereotactic radiotherapy.
- Treatment of clinical stage I non-small cell lung cancer may be delayed.
National Institutes of Health
April 21, 2020
Critical Care Considerations
- Aerosol-generating procedures should be performed in a negative-pressure room, and health-care workers are recommended to wear fit-tested respirators (such as N95 respirators or powered air-purifying respirators). For all other care, surgical masks with PPE are adequate.
- Resuscitation in patients with COVID-19 should be preferably done with balanced crystalloids, and dynamic parameters of fluid responsiveness are recommended over static parameters, a conservative fluid strategy similar to ARDS.
- Norepinephrine should be the first-line agent, with the addition of vasopressin or epinephrine to raise MAP or decrease norepinephrine dosage. Dobutamine is recommended in persistent shock despite fluids and vasopressors.
- HFNC is recommended over NIPPV in persistent hypoxemia despite conventional O2 therapy. NIPPV may generate aerosol spread and increase nosocomial transmission. Patients should be closely monitored for worsening respiratory status, and early intubation should be considered.
- Customary ARDS care should be provided to mechanically ventilated COVID-19 patients, including low Vt (4-8 ml/Kg of predicted body weight), Pplat <30 cm H20, high PEEP strategy, prone positioning, neuromuscular blockade, etc.
Therapeutic Options Currently Under Investigation
- No drug has been proven to be safe and effective for COVID-19 yet.
- Management of all patients with COVID-19 should include infection prevention/control measures and supportive care.
- There are insufficient clinical data to recommend for or against using antivirals (hydroxychloroquine/chloroquine or remdesivir) or immune-based therapy (convalescent plasma, hyperimmune immunoglobulin, IL-6 inhibitors, IL-1 inhibitors).
Concomitant Medications
- People with COVID-19 should continue chronic medications as prescribed by treating physicians, including ACE inhibitors, ARBs, inhaled or oral corticosteroids, statins, and NSAIDs; otherwise, these therapies should be used in the context of a clinical trial.
- There is insufficient evidence to recommend for or against systemic corticosteroids for intubated patients with ARDS.
- Systemic corticosteroids are not recommended for noncritically ill patients or patients without ARDS.
American College of CHEST Physicians
April 11, 2020
- There is high likelihood that the number of critically ill patients will overwhelm hospital systems during the COVID-19 epidemic.
- When a regional health system is no longer able to care for an overwhelming number of critically ill patients, a triage plan is necessary to ensure the greatest benefit to the greatest number, and to reduce the number of patients who will be unable to receive critical care resources.
- Triage systems should apply to all critically ill patients during pandemics, not solely to those afflicted by COVID-19.
- Triage decisions should be made by a dedicated triage team, distinct from the primary team providing bedside care.
- Patients who are not allocated critical care resources due to triage must still receive the best possible supportive care, including palliative care if appropriate. All patients must be provided care.
Infectious Diseases Society of America
April 11, 2020
- For patients admitted with COVID-19, the IDSA recommends the following in the context of a clinical trial: hydroxychloroquine/chloroquine, azithromycin, lopinavir/ritonavir, tocilizumab, and convalescent plasma.
- For patients admitted with COVID-19 pneumonia, corticosteroids are not suggested for use.
- For patients admitted with ARDS due to COVID-19, corticosteroids are recommended in the context of a clinical trial.
Fleischner Society
April 7, 2020
This guideline addresses the role of CXR and chest CT in managing adults with COVID-19 across a breadth of health-care environments. The choice of imaging modality (CXR vs CT) is left to the judgment of clinicians accounting for the differing attributes of CXR and CT, local resources, and expertise.
- Imaging is indicated in the following circumstances: 1) for patients with moderate to severe features of COVID-19 (eg, hypoxemia, moderate-to-severe dyspnea) regardless of COVID-19 test results; and 2) for patients with COVID-19 and evidence of worsening respiratory status.
- In a resource-constrained environment where access to CT is limited, CXR may be preferred for patients with COVID-19 unless features of respiratory worsening warrant the use of CT.
- Imaging is not indicated in the following circumstances: 1) as a screening test for COVID-19 in asymptomatic individuals; and 2) for patients with mild features of COVID-19 (eg, absence of hypoxemia, no or mild dyspnea) unless they are at risk for disease progression (age >65 years, cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer).
- Daily chest radiographs are not indicated in stable, intubated patients with COVID-19.
- CT scan is indicated in a patient who has functional impairment and/or hypoxemia after recovery from COVID-19.
- COVID-19 testing is indicated in a patient who is found incidentally to have findings suggestive of COVID-19 on a CT scan.
American Thoracic Society
April 6, 2020
Consensus-based suggestions were made in favor of the following interventions:
- Hydroxychloroquine or chloroquine for use in hospitalized patients with confirmed COVID-19 infection who have evidence of pneumonia, following protocols and employing shared decision-making with discussion of risks and benefits that enable informed patient consent;
- Prone ventilation for refractory hypoxemia with use of adequate PPE; and
- ECMO if prone ventilation fails.
No suggestions for or against therapy in hospitalized patients with COVID-19 and pneumonia were offered for the following pharmacotherapies, which are largely in early phases of investigation.
- Remdesivir is presently under study.
- Lopinavir-ritonavir combination has completed trial with negative results.
- Tocilizumab should be studied in a randomized controlled trial.
- Systemic corticosteroid usage has garnered an array of opinion (see discussion in full document).
Society of Critical Care Medicine and the European Society of Intensive Care Medicine
March 27, 2020
- Aerosol-generating procedures should be performed in a negative pressure room, and health-care workers are recommended to wear fitted respirator masks. For all other care, regular masks are adequate.
- Resuscitation in patients with COVID-19 should preferably be done with balanced crystalloids using a conservative fluid strategy similar to ARDS. Empiric antimicrobials are recommended.
- Norepinephrine should be the first-line agent, with the addition of vasopressin for refractory hypotension and dobutamine if there is persistent shock with evidence of cardiac dysfunction despite fluids and vasopressors.
- Supplemental oxygen should target Spo2 between 92% and 96%. HFNC can be considered over NIPPV. The risk of potential transmission with NIPPV to health-care workers is unknown. Early intubation should be considered.
- Customary ARDS care should be provided to mechanically ventilated patients with COVID-19, including low TV (4-8 mL/kg of predicted body weight), Pplat <30 cm H20, high PEEP strategy, prone positioning, neuromuscular blockade, etc.
American College of Chest Physicians, Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, Anesthesia Patient Safety Foundation, American Association of Critical-Care Nurses, and American College of Chest Physicians
March 26, 2020
With current equipment designed for a single patient, medical societies recommend that clinicians do not attempt to ventilate more than one patient with a single ventilator while any clinically proven, safe, and reliable therapy remains available (ie, in a dire, temporary emergency).
American College of Chest Physicians, American Association of Critical-Care Nurses, American Thoracic Society, and Society for Critical Care Medicine
March 25, 2020
For the protection of patients and health-care providers, medical societies urge the US federal, state, and local governments to maintain and strengthen social distancing requirements.
American Society of Nephrology
March 21, 2020
- The exact incidence of acute kidney injury (AKI) in patients with COVID-19 is unclear.
- Each institution should use its established RRT practices and equipment to manage COVID-19 patients with AKI or end-stage renal disease. Hasty institution of new procedures or methods outside of a center’s expertise will likely increase errors that may affect patient safety.
- Nephrologists, dialysis staff, and ICU staff will follow the CDC-recommended guidelines for personal protective equipment and safety in the care of these patients.
- Guidance regarding RRT-machine disinfection AND approved disinfection cleaning products for COVID-19 can be found at the CDC and EPA (List N) websites.
American Association for Bronchology and Interventional Pulmonology
March 19, 2020
- Bronchoscopy is contraindicated in patients with suspected and confirmed COVID19 infections.
- Because it is an aerosol-generating procedure that poses substantial risk to patients and staff, bronchoscopy should have an extremely limited role in diagnosis of COVID-19 and only be considered in intubated patients if upper respiratory samples are negative and other diagnosis is considered that would significantly change clinical management.
- Postponement of all non-urgent bronchoscopy procedures is recommended through May 2020.
Intensive Care Society of Ireland
March 18, 2020
This document provides supplementary guidance to that offered by the World Health Organization and highlights transmission facts, infection control measures, use of personal protective equipment, point-of-care testing, management of hypoxic respiratory failure, intubation, and patient transfer.
CHEST—Natural disasters, industrial accidents, terrorist attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This 12-chapter CHEST consensus statement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials.
Planning for Care During Pandemics and Disasters
Duration: 43 min
Moderator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHEST
Participants: Michael D. Christian, MD, FRCPC, FCCP; Niranjan Kissoon, MBBS, FRCPC; Christian E. Sandrock, MD, MPH, FCCP
Recommendations from CHEST Journal Articles
Surge Capacity Principles
FULL RECOMMENDATIONS |
FULL ARTICLE
- Base planning on the projected number of critically ill or injured patients resulting from specific scenarios, including consideration of ICU patient care requirements over time and resource constraints that may limit the ability to provide care.
- Create standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.
Surge Capacity Logistics
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FULL ARTICLE
- Planning for staff and resource augmentation involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities.
- Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals.
- Specialized physician oversight is necessary, and if not available on site, may be provided through remote consultation.
- Triage by experienced providers, reverse triage, and service de-escalation may be used to minimize ICU resource consumption.
- During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.
Evacuation of the ICU
FULL RECOMMENDATIONS |
FULL ARTICLE
- Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers.
- All critical care providers have a professional obligation to become better trained, prepared, and engaged with the process of ICU evacuation to provide a safe continuum of critical care during a disaster.
Triage
FULL RECOMMENDATIONS |
FULL ARTICLE
- Significant planning, preparation, and infrastructure are required for ethical and efficient triage.
- Prognostic tools required to produce an effective decision support system (triage protocol) are lacking along with most of the infrastructure, processes, legal protections, and training for critical care triage.
- Employ triage as a last resort after leveraging mass critical care surge strategies.
Special Populations
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FULL ARTICLE
- Pre-identify medically fragile and chronically ill patients during disaster planning.
- Preparation on all levels is necessary to mitigate a disaster's impact on this population who will likely decompensate and may need scarce critical care resources.
- The model offered by the Kidney Community Emergency Response Coalition provides a templated approach that may prove useful in other special populations.
System-Level Planning, Coordination, and Communication
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- Focus on joint communication tools and processes; identification and sharing surge resources, including location, quantity, and how to access them quickly; planning for pediatric populations as usual (not special) care; and understanding internal transfer networks to optimize potential transfers both within their region and to neighboring healthcare coalitions and regional authorities.
- Ensure representation of critical care specialists among leadership of healthcare coalitions and regional authorities.
Business and Continuity of Operations
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FULL ARTICLE
Employ six key strategies to ensure continuity and efficient supply chain management:
- Use multiple suppliers to purchase key critical care supplies and medications.
- Identify commonly used critical care products and alternatives for which providers at the facility already have some degree of familiarity.
- Use computer systems that integrate purchasing, storage, and use of medical supplies and medications through technologies such as radio-frequency identification or other bar code system to allow a real-time inventory monitoring.
- Increases to purchasing should be incremental rather than in bulk, both to minimize expense and avoid sudden demand on an already vulnerable supply chain.
- Institute protocols to restrict use of the product in shortage or encourage use of alternatives.
- Support ongoing efforts from policy makers and national and international governmental and nongovernmental organizations to reduce supply chain vulnerability in medical supplies and medications.
Engagement and Education
FULL RECOMMENDATIONS |
FULL ARTICLE
- Optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals.
- Effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.
Legal Preparedness
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FULL ARTICLE
- Most US agencies have disaster plans in place and recognize the duty and imperative for coordinating with other local, regional, and federal partners.
- Various legal protections for specific responders have been enacted at the local, state, and federal levels. Health disaster response planning and coordination have also evolved at the international level.
- No single approach can provide a shield from all claims of liability. However, transparent, consistent decision-making among health-care entities and practitioners during responses may provide important liability protections to health-care entities and practitioners for good faith actions during emergencies.
Ethical Considerations
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- Triage and allocation of scarce critical care resources remain persistently controversial issues in public health emergencies.
- While there are best practices regarding ethical policies that may be adopted, additional research and reflection on these key ethical issues are warranted.
Resource-Poor Settings: Infrastructure and Capacity Building
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FULL ARTICLE
- Capacity building entails preventative strategies and strengthening of primary health services.
- Assistance from other countries and organizations is needed to mount a surge response.
- Planning should address when to disengage and how the host nation can provide capacity beyond the mass casualty care event.
Resource-Poor Settings: Response, Recovery, and Research
FULL RECOMMENDATIONS |
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- Knowing limitations early in a disaster response will guide patient-care activities that can be supported once response groups disengage.
- Future mass critical care efforts in resource-poor settings require more evidence-based actions and quality improvement initiatives.