COVID-19 Guidelines, Statements, and Research

Lessons Learned About Aerosol Drug Delivery in the Era of COVID-19

By: Arzu Ari, PhD, RRT, PT, CPFT, FCCP, and J. Brady Scott, PhD, RRT, RRT-ACCS, AE-C, FCCP
Respiratory Care Network
Published: July 30, 2021

Reasonable concerns exist regarding the transmission risk of COVID-19 due to aerosol dispersion. This article provides clarity on lessons learned during the COVID-19 pandemic and summarizes suggestions based on the best available evidence.

Lung Transplantation for the Treatment of COVID-19 Fibrosis

By: Grant A. Turner, MD, MHA, and Laura Frye, MD
Transplant Network
Published: July 27, 2021

Some patients who survive COVID-19 may be left physically debilitated and have significant residual pulmonary fibrosis. We review the research regarding the use of lung transplant in COVID-19.

Immunomodulation Therapy in Severe COVID-19 Infection: Where Do We Stand?

By: Damaris E. Pena Evertz, MD, and Bharat Bajantri, MD
Clinical Research and Quality Improvement Network
Published: June 15, 2021

How effective is immunomodulation therapy in treating patients with severe COVID-19 infection? Learn about the research into various treatments.

Clinical Outcomes of COVID-19 in Patients With COPD

By: SM Abdullah Al Mamun, MD, MBBS, FCCP; Muhammad Adrish, MD, MBA, FCCP; Tamer Hudali, MD, MPH; Mahesh Padukudru Anand, DNB, MBBS, FCCP; Fernando Fuentes, MD; Sarang Patil, MD; Kadambari Vijaykumar, MD; and Navitha Ramesh, MD, MBBS, FCCP
Airways Disorders Network
Published: June 15, 2021

Understand the increased risk of severe COVID-19 in patients with COPD, as well as strategies for implementing telehealth for patients with COPD during the pandemic.

Diagnosis and Containment of Patients With Suspected Lung Cancer in the COVID-19 Pandemic—What Does the Literature Say?

By: Jasleen Pannu, MD
Thoracic Oncology Network
Published: June 2, 2021

The COVID-19 pandemic has had a detrimental impact on the already complex care of patients with lung cancer.

Safety of Bronchoscopy During the COVID-19 Pandemic: An Update

By: Abhishek Sarkar, MD; Abhinav Agrawal, MD, DAABIP; Anne Valerie Gonzalez, MD, FCCP; Fabien Maldonado, MD, FCCP; and Christina MacRosty, DO
Interventional/Chest Diagnostic Procedures Network
Published: May 18, 2021

More than a year after the start of the pandemic, we reflect upon the evidence regarding bronchoscopy during the COVID-19 pandemic.

Proning in COVID-19 Patients

By: Mary Jo Farmer, MD, PhD, FCCP; Claudia Onofrei, MD, MSc; and Salim Surani, MD, MPH, MSHM, FCCP
Clinical Pulmonary Medicine Network
Published: May 17, 2021

Prone positioning with or without mechanical ventilation has been widely adopted in treating patients with respiratory failure due to COVID-19. Previous experience in patients with moderate to severe acute respiratory distress syndrome demonstrated a survival benefit associated with early application of prone positioning.

Pulmonary Vasculopathy and Thrombosis in Patients with COVID-19

By: Dana Kay, DO; Sandeep Sahay, MD, MSc, FCCP; and Jean M. Elwing, MD, FCCP
Pulmonary Vascular Disease Network
Published: May 7, 2021

COVID-19 has proven to affect multiple organ systems through the activation of inflammatory and coagulation cascades. One fundamental area researched has been the pulmonary vascular changes and the incidence of thrombosis observed in COVID-19 patients.

COVID-19 and Pregnancy

By: Amik Sodhi, MD; Dipen Kadaria, MD; Jorge Trabanco, MD; Zachary Burden, MD; and Mariam Louis, MD
Women’s Lung Health Network
Published: April 30, 2021

Find out whether COVID-19 is more severe in pregnancy, how the disease may affect the fetus/neonate, whether pregnant patients should get the COVID-19 vaccine, and current recommendations regarding the relationship of the COVID-19 vaccine to fertility.

Operationalizing Crisis Standards of Care: The Potential Hazards of Relying on SOFA Scores for Resource Allocation

By: Brandon Corbett Walsh, MD, MBE, and Aloke Chakravarti, MD, FCCP
Disaster Response and Global Health Network
Published: April 23, 2021

A utilitarian resource allocation policy requires a prognostication model that aims to select individuals who are most likely to survive, but does so in a fair, transparent, and consistent manner that does not worsen existing health disparities. To date, however, no prognostication tool exists to predict mitigated outcomes of critical illness during a pandemic.

Post-COVID-19 Recovery Care: The Need for the Interprofessional Approach

By: Mary Jo S. Farmer, MD, PhD, FCCP, and Munish Luthra, MD, FCCP
Interprofessional Team Network
Published: April 22, 2021

Multipronged, interprofessional collaborative recovery care programs are urgently required to identify and address the unique needs of COVID-19 survivors and adapt to the shifting logistical landscape of the ongoing pandemic.

Toci Si or Toci No – The Tocilizumab Dilemma

By: Marcos I. Restrepo, MD, MSc, PhD, FCCP
Chest Infections Network
Published: April 19, 2021

Despite the use of corticosteroids, the mortality rate in severe and critical cases of COVID-19 remains unacceptably high. This is why the Chest Infections Network has chosen to review the literature on the use of tocilizumab (TCZ) to suggest alternatives for clinicians to improve survival among critically ill patients affected by COVID-19.

Aerosolization Risks of Noninvasive Ventilation in the Era of COVID-19

By: Sherri L. Katz, MDCM, MSc, FRCPC, FCCP; Meredith Kendall Greer, MD; and Ashima S. Sahni, MD, FCCP
Home-Based Mechanical Ventilation and Neuromuscular Disease Network
Published: April 9, 2021

Noninvasive ventilation is widely used in the treatment of patients with both acute and chronic respiratory disease. Understand the aerosolization risks of NIV in the era of COVID-19.

Aerosol Generation Risk of Chest Physiotherapy and Airway Clearance Techniques in Patients With COVID-19

By: Sherri L. Katz, MDCM, MSc, FRCPC, FCCP; Meredith Kendall Greer, MD; and Ashima S. Sahni, MD, FCCP
Home-Based Mechanical Ventilation and Neuromuscular Disease Network
Published: April 9, 2021

Certain precautions are necessary when delivering chest physiotherapy and airway clearance in patients with COVID-19, given the possibility of greater aerosolization of secretion with these therapies.

Asthma and COVID-19

By: Farrukh Abbas, MBBS; Diego Maselli, MD, FCCP; Mahesh Padukudru Anand, MBBS, FCCP; and Navitha Ramesh, MD, MBBS, FCCP
Airways Disorders Network
Published: March 22, 2021

Asthma exacerbations triggered by viral infections can be associated with adverse outcomes. Are asthma patients at increased risk of complications from COVID-19-related respiratory disease? Recent evidence suggests otherwise.

Timing of Intubation in Patients With COVID-19

By: Casey Cable, MD, MSc; David Bell, MD; Alice Gallo de Moraes, MD; and Viren Kaul, MD
Critical Care Network
Published: March 16, 2021

The timing of intubation in hypoxemic patients with COVID-19 has been hotly debated, with experience and guidelines evolving over the course of the pandemic. However, the clinical question persists: When is the “right time” to intubate hypoxemic patients with COVID-19?

Obstructive Sleep Apnea as a Risk Factor for Adverse Outcomes in COVID-19

By: Kara Dupuy-McCauley, MD, and Lauren Tobias, MD
Sleep Medicine Network
Published: March 3, 2021

Obstructive sleep apnea (OSA) shares several risk factors with COVID-19, including an increased incidence and severity in patients with male sex, obesity, hypertension, diabetes mellitus, and cardiovascular disease. The authors briefly review emerging literature that suggests OSA may be an independent risk factor for poor outcomes from COVID-19.

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19

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.

The Role of Chest Imaging in Patient Management During the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society

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.

COVID-19: Interim Guidance on Management Pending Empirical Evidence 

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).

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

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.

Recommendations on the Care of Hospitalized Patients With COVID-19 and Kidney Failure Requiring Renal Replacement Therapy (RRT) 

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.

Statement on the Use of Bronchoscopy and Respiratory Specimen Collection in Patients with Suspected or Confirmed COVID-19 Infection 

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.

Guidance Document for the Intensive Care Management of the Adult Patient with Confirmed or Suspected COVID-19 

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.