Management of COVID 19

infected patients
FAQs for HCWs v1 made on 4th May, 2021
Based on existing evidence, resources, and practice experience.
Please note that this may undergo changes in the coming days as evidence changes

Dr Swathi SB, MBBS, FHM, Primary care physician and researcher,

PCMH Restore Health, Bangalore.

With inputs from Dr Ramakrishna Prasad, MD, MPH, Family physician

and Infectious disease specialist. Founder & Director, PCMH Restore
Health.
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Learning objectives

● Know the pathophysiology and course of COVID 19 disease.

● To be able to diagnose COVID 19 infection, identify severity of illness at the
community setting.
● To be able to get evidence based answers to questions that could help in
planning management strategies for COVID-19 infected patients in
community setting and cordinate care based on severity of infection and level
of care required.

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Test results are taking long, how to diagnose
infection and identify severity?

● RT-PCR is the mainstay for diagnosis of COVID-19 infection. RAT (Rapid

antigen test) has low sensitivity and poor negative predictive value (NPV). But
due to the current numbers, burden for RT-PCR is increasing and hence results
are taking 3 days or longer. And so all persons with COVID like symptoms
should be practically treated as COVID 19 infected in the current situation.

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 Severity classification

If RR and SpO2 measurements h/o persistent severe cough/high temp,

not immediately feasible watch shortness of breath, severe comorbidities
for-
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What is the course of COVID 19?
The illness like some other viral infections (like dengue etc) has phases.

3 main phases apart from incubation period.

Phase 1: upto 7 days - Early infection/ symptomatic phase where we see all the flu-like symptoms and
where usually people present to clinics/doctors. (in majority saturation remains stable in this phase)
Phase 2: 7th-10th day - Early pulmonary phase where viremia reduced but inflammatory response takes
over causing ground glass opacifications in the lungs, drop in saturation begins here. Hence the most crucial
time to watch out for. Here is where anti-inflammatory drugs like inhaled Budesonide, oral
Prednisolone/Methylprednisolone helps!
Phase 3: 10th-28th day - Hyperinflammatory stage with late pulmonary changes (a few move on to this
severe phase) - cytokine storming, resulting in severe dyspnea, drop in SpO2, needing hospitalisation/
oxygen support etc.

Hence knowing the day of onset of symptoms becomes important in order to expect the clinical course of
our patients and educate them. To note here, the start date reported by patients can often be incorrect as
they may ignore 1-2 days of headache/fatigue/bodyache. Or might tell the date of testing. Also the changes
of them relaxing after 7 days is high as fever and other symptoms would come down. (But that's critical time
to look out for) 5
Note that here day 1 is the day of exposure whereas we usually count day of developing symptom as day 1. So in
the figure the incubation period is included in the days. (So day 12 is actually day 7, and day 15= day 10)
References:
https://www.evms.edu/media/evms_public/departments/internal_medicine/Marik_Critical_Care_COVID-19_Protocol.pdf 6
What are the key counseling messages
1. Most patients recover without need for hospitalisation and so DO NOT panic
and that you are there for support
2. Importance of having report for RT-PCR (especially for potential need for
admission)
3. Importance of monitoring SpO2, temperature, PR, RR warning signs and
reporting
4. Home isolation steps for self and family including adequate ventilation
5. Hydration with minimum 3L (ORS+water+butter milk with salt, lime juice/
tender coconut water etc) and intake of food at regular times.
6. Counseling regarding when hospitalisation will be required and how to have
details ready for the same

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How to recognise early warning/red flags?
Apart from SpO2, RR and h/o shortness of
breath
● Feeling short of breath while talking
to you over phone (can’t finish
sentences)
● Over video call - you can assess RR,
cyanosis, use of accessory muscles of
respiration, wheeze, nasal flaring,
walking around the room causing
shortness of breath
● Severe diarrhoea
● Confusion/disorientation/ agitation
● Not able to eat/drink
● Extreme fatigue

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References: https://line.17qq.com/articles/gpbigfbhz_p3.html
What are early interventions at home to prevent
hospitalisation or till bed availability
When saturation <93% at home or RR>24 cpm, seeking hospital care is recommended. Some
early interventions that can be done at home include -

1. Proning position
2. Inhaled (MDI or nebulisation) with Budesonide 800 mcg BD or 1mg respules
3. Oral steroids (Dexamethasone/ Methylprednisolone/ Prednisolone / Prednisone) -
especially after day 5 which is the pulmonary immune response phase.
4. Oxygen - if oxygen concentrator or cylinder available - till hospital admission arranged.

Details in next slide

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 10
References:Tips for managing COVID-19 at home for Adults poster by https://www.indiacovidsos.org/home-care
 How to check for SpO2?
How to use your pulse oximeter and Covid-19 diary - NHS Reasons of incorrect
https://www.youtube.com/watch?v=ifnYjD4IKus readings
(watch at least till 2:14 duration in this video) ● Nail varnish or
pigment on finger
Step 1:Remove any nail polish or false nails and warm the hand
● Bright light on the
Step 2: Rest for 5 min before taking the reading probe
● Patient movement
Step 3: Rest your hand at the heart level and hold it still for a few minutes. ● Poor perfusion (cold
Step 4: Switch on the pulse oximeter and place it on the middle/index finger hands, hands
washed in cold
Step 5: The reading takes time. So keep it at least for a minute/ longer if not water)
stable

Step 6: record the highest reading. That has to be stable at least for 5 seconds.

References:https://www.who.int/patientsafety/safesurgery/pulse_oximetry/who_ps_pulse_oxymetry_tutorial2_advanced_en.pd 11
 Role of nebulisation/ inhalation and steroids?
When and how much?
For persistent/ severe cough (beyond 5 days) OR moderate infections (saturation
90-93%) - inhaled budesonide to be given 800mcg MDI BD to QID (2-3 puffs) or
nebulisation with 1mg budesonide respules for 5-7 days.

Steroids shown to be benefit moderate and severe cases (saturation <93%) and to
be started with dose as described in previous slide. (Best effect when started after 5
days of initial viremia related symptoms).

References: AIIMS revised protocol 3rd May, 2021, 12

https://www.evms.edu/media/evms_public/departments/internal_medicine/Marik_Critical_Care_COVID-19_Protocol.pdf
 How to use oxygen concentrator?

https://youtu.be/GtX9CV7-EIU - How to use oxygen concentrator at Home

by Dr. Bornali Dutta

A video explaining the oxygen contractor mechanism and how to use.

https://www.youtube.com/watch?v=k86zyk1iGw4 Video explaining how to use

oxygen cylinder at home

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Should we prescribe antimicrobials?

There is NO evidence for efficacy of antimicrobials against COVID 19. And hence
is not recommended for all patients unless a bacterial co-infection is suspected.

In mild cases - not recommended.

In moderate cases - only if clinical suspicion of a bacterial infection.

In severe cases - empiric antimicrobials to treat all likely pathogens, based on

clinical judgment, patient host factors and local epidemiology, and this should be
done as soon as possible (within 1 hour of initial assessment if possible)

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References: COVID-19 Clinical management: living guidance https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
Which are the drugs having no evidence and not
recommended?
Antimicrobials Immune modulators: Others
Azithromycin Baricitinib Vitamin C & D
Ivermectin Bevacizumab Fluvoxamine
Doxycycline
Convalescent Plasma
Favipiravir
Itolizumab
Lopinavir-Ritonavir
Interferon alpha-2b
Hydroxychloroquine (HCQs)

References:https://www.indiacovidsos.org/home-care , AIIMS revised protocol May 3rd, 2021 15

https://www.who.int/publications/i/item/WHO-2019-nCoV-therapeutics-2021.1
 Other drugs being used (investigational)
Remdesivir: (anti-viral) According to WHO recommendation - there is uncertain evidence
regarding its benefit and harm. Review could not conclude that it’s ineffective. Being preferred
by physicians and patients in severely ill patients. Here is a decision aid for applying evidence
to patient needs: https://app.magicapp.org/#/guideline/nBkO1E/section/Egz0xn

Tocilizumab (off-label): (IL-6 inhibitor) Used in specific circumstances under physician

guidance in severely ill hospitalised patients. “Among hospitalized adults with progressive
severe* or critical** COVID-19 who have elevated markers of systemic inflammation, the IDSA
guideline panel suggests tocilizumab in addition to standard of care (i.e., steroids) rather than
standard of care alone. (Conditional recommendation, Low certainty of evidence)”. ICMR had
recommended against it’s use but current recommendations by ICMR aren’t clear.
References: https://www.who.int/publications/i/item/WHO-2019-nCoV-therapeutics-2021.1
AIIMS revised protocol May 3rd, 2021
https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/ 16
 Can NSAIDs be prescribed?
● April 2020: At present there is no evidence of severe adverse events, acute health care
utilization, long-term survival, or quality of life in patients with COVID-19, as a result of
the use of NSAIDs.
https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-i
nflammatory-drugs-(nsaids)-in-patients-with-covid-19 (that reviewed 73 studies All
studies were concerned with acute viral respiratory infections or conditions commonly
caused by respiratory viruses, but none specifically addressed COVID-19, SARS, or
MERS)
● March 2021: Prospective Study in Saudi Arabia: Acute or chronic use of ibuprofen and
other NSAIDs was not associated with worse COVID-19 disease outcomes.
● Even GoK guideline suggests for fever not responding to only Paracetamol, other
NSAIDs like Naproxen can be given

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 Who will benefit from Anticoagulants? and which
one?
Thromboprophylaxis (for moderate and severe cases hospitalised)
WHO: Conditional recommendation for
In hospitalized patients with COVID-19, without an established indication for higher
dose anticoagulation, we suggest administering standard thromboprophylaxis dosing
of anticoagulation rather than therapeutic or intermediate dosing (conditional
recommendation, very low certainty)
ICMR and AIIMS protocol - prophylactic dose of UFH or LMWH enoxaparin
0.5mg/kg/day s/c or 40mg s/c (for low body weight women <45kg and men <57kg -
better weight adjusted dosing)
References: COVID-19 Clinical management: living guidance https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1
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AIIMS revised protocol 3rd May, 2021
If a patient is already on Aspirin for other medical
reasons, can it be continued?

Yes. Patients who are receiving anticoagulant or antiplatelet therapies for

underlying conditions (DM, cardiac issues, RA, etc including pregnant women)
should continue these medications if they receive a diagnosis of COVID-19
(AIII-strong expert opinion)

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References: NIH COVID 19 treatment guidelines https://www.covid19treatmentguidelines.nih.gov/antithrombotic-therapy/
Should the hematologic and coagulation parameters
be tested for all? (D-dimer, PT, platelet..)
● In nonhospitalized patients with COVID-19, there are currently no data to support
the measurement of coagulation markers (e.g., D-dimers, prothrombin time, platelet
count, fibrinogen) (AIII).
● In hospitalized patients with COVID-19, hematologic and coagulation parameters are
commonly measured, although there are currently insufficient data to recommend
either for or against using this data to guide management decisions.

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References: NIH COVID 19 treatment guidelines https://www.covid19treatmentguidelines.nih.gov/antithrombotic-therapy/
What about anticoagulants for non-hospitalised
patients?
● NIH guidelines states: For nonhospitalized patients with COVID-19, anticoagulants
and antiplatelet therapy should not be initiated for the prevention of VTE or arterial
thrombosis unless the patient has other indications for the therapy or is participating in
a clinical trial (AIII).
● But because in the current situation of lack of bed availability at times, some moderate
and severe patients may be at home. So what about for them? There is still no evidence
from RCTs for recommendation regarding use of anticoagulants so far (including oral
aspirin, DOACs- apixaban, rivaroxaban etc) for prophylaxis. Several RCTs are in
progress (as shown in pic on slide 30) and hopefully we would have evidence in the
coming days. Hence there is no recommendation to give to all patients but decision is
taken case by case basis.

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References: NIH COVID 19 treatment guidelines https://www.covid19treatmentguidelines.nih.gov/antithrombotic-therapy/
 22
References: https://www.sciencedirect.com/science/article/pii/S0735109721004587?via%3Dihub
Will people vaccinated not get infected? How to
counsel?
Purpose of vaccination:

1. To protect the front-line workers

2. Reduce mortality
3. Interrupt the pandemic

Hence though not all will be protected against the infection and you still have a
chance of getting the infection even after 2 doses of vaccination, almost 100%
would be protected from having severe illness.

References: https://www.youtube.com/watch?v=Vd1CoH8ta2g Interview with Gagandeep Kang

https://thewire.in/health/watch-take-second-covishield-jab-after-28-days-its-safe-practical-simple-dont-delay-dr-shahid-jameel 23
Interview with Shahid Jameel
 Airborne transmission or not?
Airborne transmission is defined as the spread of an infectious agent caused by the dissemination of
droplet nuclei (aerosols) that remain infectious when suspended in air over long distances and time

● Controversial, but WHO ruled out that COVID 19 can spread through
airborne transmission
● Although maintaining good ventilation in home spaces is recommended.

References:
https://rangaudaykumar.medium.com/perhaps-the-coronavirus-can-spread-by-air-but-the-real-problem-is-elsewhere-8ae86d 24
72dc1f
Are you feeling overwhelmed/ overburdened?
What can you do?
- It is understandable with the current burden of pandemic.
- Acknowledge that you are doing your best and it is okay to be tired or take rest.
- When feeling afraid or helpless, ask yourself: “What is under my control?”
“When I have been stressed in the past, how have I managed?” “What are the
things I can do to help myself?”
- Identify “feeling low” and do reach out to your supervisor/ friends/ carers for
emotional support.
- Stay hydrated and have adequate food breaks
- Do not hesitate to take professional help - few helplines suggested on net slide

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References: https://www.mohfw.gov.in/pdf/MindingourmindsduringCoronaeditedat.pdf
Mental health support
for HCWs
iCall by TISS: 9152987824 between
Monday and Saturday from 10 am
to 06 pm
Being a frontline worker, if you're
feeling overwhelmed or if someone
you care about or know is
experiencing psychosocial distress,
reach out for support and help at
SWAASTHI
https://icallhelpline.org/swaasthi-re
sources/

26
 Case history 1
● 55 yrs old, male with h/o fever and stomach discomfort, one episode of loose stool since
1 day. Had recently travelled to his village but using personal transport. RT-PCR was
advised, suspected COVID 19 infection. Not vaccinated for COVID 19. No comorbidities.
SpO2: 96%, Temp: 100.2 deg F, RR- 22 cpm, PR, 108 bpm. No cough, sore throat, cold. 6
min walk test - no change in SpO2 reading.
● Advised - Paracetamol 500/650 mg stat and SOS. ORS and hydration with adequate
fluids, isolation from his wife and son advised.
● Test came positive within one day (private lab). Continued the same treatment and
monitoring chart with the above parameters for the next 14 days.

Over the days, he developed cold, blocked nose, fatigue, sleeplessness. Advised nasal drops,
steam inhalation, rest, hydration, and monitoring as above. He recovered well and there were
no complications. Now 21 days are past.
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 Case history 2
● 17 yrs old boy, developed fatigue since previous evening and a saturation of 89-91% that
morning. No breathlessness/ cough/ wheeze. Had fever, fatigue and runny nose. h/o asthma
but no episodes in the last one year and not requiring regular treatment for it. RR: 26cpm,
Temp: 100 F, PR: 110 bpm, weight ~ 55kg
● At home - Immediately advised to lie in prone position, start on Budecort nebulisation 1mg
respules QID, Tab Methylprednisolone 32 mg stat. With nebulisation, saturation picked up
to 91-93%. Meanwhile, provider and parents contacted for renting an oxygen concentrator
as a back up if required.
● Tab Methylprednisolone 32mg was continued for 5 days and reduced to 16mg for the next 3
days. He developed dry cough on day 5 but subsided by day 7. Fatigue continued but
saturation has been maintaining so far (day 8 currently)
● Since he had one episode of drop of saturation to 86% on day 6 morning, (which picked up
with nebulisation) chest CT was advised and the CT score was zero. Hence the above
treatment was continued. Day 9 - maintaining saturation and recovering.
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 Case history 3
● 36yrs old, male, with h/o fever and cough since 5 days. Tested positive for RT PCR 2 days
ago. Known to have HIV and on ART since 2 months. No other comorbidities. Was tested
negative for TB while initiating ART. CD4 : 250.
● He had already been started on Azithromycin 500mg, Doxycycline 100mg BD, Pan
40mg, T Aceclofenac+Paracetamol, Vit D, Vit C, Cetirizine at a private clinic.
● Had severe cough, nose block, fatigue and fever episodes continued. On video call, RR:
26, no use of accessory muscles of respiration or other signs of inadequate breathing.
SpO2: had no access.
● Since cough was persistent and severe, RR was high, MDI Budenoside 2 puffs 3 times
was advised. As there was no access to monitor SpO2, Tab Methylprednisolone has also
been started since 2 days. (On day 8 - he is doing better, being monitored at home)

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Topics to be added in the coming days

● Please note that this is an evolving document as more FAQs arise and
evidence changes
Things we intend to add-
● Bed allocation queries
● RT PCR negative COVID 19 like illness
● Dealing with COVID 19 in pregnant women
● Further clarification on use of anticoagulants

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Credits

Prepared by Dr Swathi SB, MBBS, FHM, a Primary care physician and

researcher at PCMH Restore Health, Bangalore. swathisb01@gmail.com
With inputs from Dr Ramakrishna Prasad, MD, MPH, Family physician and
Infectious disease specialist. Founder & Director, PCMH Restore Health.
dr.rk.prasad@gmail.com
If you’d like to contribute to the topics mentioned in previous slide or any
relevant topics to this documents, please do write to us.

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