Clinical guidance for the management of COVID-19 has been published by the pioneer- All India Institute of Medical Sciences (AIIMS), Delhi. The recommendations spell out how COVID patients with mild, moderate, and serious illness can be handled and the possible treatment for these patients.

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Mild illness

Symptoms of the upper respiratory tract (&/or fever) without evidence of shortness of breath or hypoxia.

Recommendation: Isolation at home

Here is what can be advised for patients:

• Take contact and droplet precautions
• Follow stringent hand hygiene
• Consider symptomatic treatment (hydration, antipyretics, antitussives)
• Maintain communication with the treating practitioner

When to seek emergency medical treatment?

Patients should be told to seek immediate treatment when they experience-

• Difficulty in breathing/RR >= 24/min
• SpO2 <94 percent
• Rising fever/severe cough, particularly after five days of onset of symptoms

A minimum threshold should be maintained for those with all of the high-risk characteristics.

• Ivermectin (200 mcg/kg once a day for 3 to 5 days) can be prescribed (avoid if pregnant or nursing)
• If a fever cannot be managed with a maximum dosage of Tab. Paracetamol 650 mg QID; an NSAID such as Tab. Naproxen 250 mg BD can also be considered
• Inhalational budesonide (800 mcg BD for 5 to 7 days through DPI, MDI with Spacer) can be used if symptoms (fever and/or cough) occur after 5 days after disease onset
• Systemic steroids are not recommended for mild disease; however, in cases of high-grade fever and severe cough lasting more than 7 days, they can be considered in consultation with the prescribing physician for a period of 3-5 days
• 0.1 to 0.2 mg/kg OD dexamethasone or 0.5-1 mg/kg methylprednisolone in two separate doses can be prescribed

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Moderate illness

Look out for the following symptoms:

• A respiratory rate of more than 24 per minute
• On room air- SpO2 <93 per cent

When should the patient get admitted to the hospital?

Once the patient is admitted to the hospital, the management should be as follows:

• Oxygen support: SpO2 target: 92-96 per cent (88-92 per cent in COPD patients)
• Desired oxygenation devices: Non-rebreathing face mask

Awake proning should be recommended in all patients who need supportive oxygen therapy and sequential position changes every 1-2 hours.

Immunomodulatory or anti-inflammatory medications

1. Inj. Methylprednisolone 0.5 to 1 mg/kg in two separate doses (or an equal dosage of dexamethasone 0.1 to 0.2 mg/kg per day) typically, can be given to patients with moderate symptoms for 5 to 10 days. If the patient is healthy and/or progressing, the oral route can be started or switched.
2. Anticoagulation prophylactic UFH or LMWH at a conventional dosage (weight-based, e.g., enoxaparin 0.5mg/kg per day SC OD) can be considered for the patient.
3. If the patient is healthy and/or progressing, the oral route can be started or switched. Anticoagulation prophylactic UFH or LMWH at a conventional dosage (weight-based, e.g., enoxaparin 0.5mg/kg per day SC OD) can also be considered.

Monitoring moderate illness

• Clinical Monitoring: Respiratory work, haemodynamic impairment, and oxygen demand changes
• Serial CXR and HRCT chest should be performed only if symptoms escalate
• CRP and D-dimer levels should be checked every 48 to 72 hours
• CBC, KFT, and LFT levels should be checked every 24 to 48 hours
• IL-6 levels should be checked if the condition deteriorates (subject to availability)

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Severe illness

Look out for any one of the following:

• Respiratory rate greater than 30 breaths per minute
• SpO2 level <90% in room air

When should the patient be admitted to the hospital?

Once the patient is admitted to the ICU, the management is as follows:

1. Aid for the respiratory system- Consider using NIV/(helmet or face mask interface, if available)/HFNC in patients with continuing to increase oxygen requirements, if work of breathing is low. If NIV is not tolerated in patients at high work of breathing, intubation should be given preference. Use standard ARDSnet protocol for ventilatory care.

Immunomodulatory or anti-inflammatory medications: Inj. Methylprednisolone 1 to 2 mg/kg IV in two separate doses (or a comparable dosage of dexamethasone 0.2 to 0.4 mg/kg per day) normally for 5 to 10 days can be considered for the patient.

Anticoagulation: An intermediate dose of prophylactic UFH or LMWH depending on body weight (e.g., Enoxaparin 0.5 mg/kg per dose SC BD) can be administered to the patient.

Steps for assistance: Keep euvolemia (use dynamic fluid responsiveness measures if accessible). If sepsis or septic shock occurs, follow the established treatment and local antibiogram.

Monitoring severe illness

• Only if the patient's condition is worsening can a serial CXR and HRCT of the chest be performed
• CRP and D-dimer levels should be tested every 24 to 48 hours in the lab
• CBC, KFT, and LFT should be tested on a regular basis
• IL-6 levels should be determined if the patient's condition deteriorates (subject to availability)

Discharge can be given as per amended discharge guidelines after the patient's clinical improvement.

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