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April 8, 2020 – International Webinar Recap

COVID-19 Patient Management: Challenges, Projections and Guidance from Temple’s Dr. Gerard Criner

Watch the April 8 webinar on "COVID-19 Management of Patients with Mild, Moderate and Severe Cases."
Watch the April 8 webinar on "COVID-19 Management of Patients with Mild, Moderate and Severe Cases."

Gerard Criner, MD, FACP, FACCP, Director of the Temple Lung Center, provided a U.S. perspective on COVID-19 treatment in a recent international webinar.

Entitled, "COVID-19 Management of Patients with Mild, Moderate, and Severe Cases," the webinar took place the evening of April 8, hosted by Broncus Medical, Inc.

Watch the full webinar or read the summary of Dr. Criner's presentation below.

COVID-19 Experience: Tri-State, U.S., and Global

Global case rates: Countries across the northern hemisphere have been severely affected by COVID-19, starting in China and East Asia, followed by a heavy occurrence in western Europe, and most recently in the United States, with a large surge in infected and critically ill patients. The U.S. currently has the highest number of COVID-19 cases worldwide.

Global death rates: Although the number of cases is highest in the United States, the other countries lead in per-capita death rate from COVID-19. Spain and Italy have had more than 200 deaths per 100,000 people; the United States and some other western European nations so far have not seen this level of fatality (U.S. death rate is closer to 100 deaths per 100,000 people). Deaths are occurring not only among the older people considered to be most at risk, but also among younger people. The fatality curve is starting to flatten in Spain and Italy.

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Projections and Observations on U.S. Cases and Deaths from COVID-19

National-level peak in diagnosed COVID-19 cases occurring now; peak hospitalizations and deaths within two weeks.

The peak in the number of new infections in the United States overall may already have occurred; this will be followed by a peak in hospitalizations. The United States projected peak need for maximum health care resources (ICU beds and invasive ventilation) was approximately April 11. The peak in the number of COVID-19 deaths will occur somewhat later.

Social distancing is effective.

Social distancing appears to be having an encouraging effect. While the impact of this pandemic is unprecedented in recent U.S. history, the number of deaths may be less than the 100,000–200,000 people projected less than a week ago. If social-distancing practices are maintained at their current level in the United States through August 1, 2020, we may see the number of deaths decrease to 60,000.

Local/regional peak times will differ.

As of April 7, the number of new reported cases in the United States appeared to be nearing an asymptote; while the curve had not yet reached that “flattening out” point, the rise in the number of new cases appeared to be less sharp than previous weeks.

However, the peak in the number of cases or deaths will not occur simultaneously across all regions. In some areas, such as parts of New York (including New York City) and New Jersey, the increase in the number of diagnosed cases has begun to slow down significantly; in others, such as areas of Michigan, Louisiana and Pennsylvania, the number of confirmed cases continues to double every 3 to 7 days (as of April 8).

Thus, the national average is less relevant for health care providers; local and regional projections are more important for managing health care resources.

Greater Philadelphia/Tri-State peak in hospitalizations will occur soon.

In the Tri-State region and Philadelphia, we were, on April 8, still on the sharp rise of the curve. Peak number of cases was expected for the weekend of April 11–12. A peak in requirements for hospital resources, including the number of ICU ventilators, will follow. The death rate will hit its peak approximately 5–6 days later.

Despite a peak in the number of U.S. cases and hospitalizations in places like New York City, the death rate has not yet hit a plateau. New Jersey, Michigan, Pennsylvania, and Louisiana are still on the sharp parts of the curve and will not reach a plateau in deaths for a time—possibly one to two weeks from April 8.

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Patient Presentation and Management

Younger patients are also affected.

COVID-19 can result in death not only in the elderly but in younger people.

Initially, COVID-19 was said to only affect patients who were older and/or infirm—older adults in nursing homes, those with comorbidities, etc. Cases from Asia and Europe have shown that this rule is not universal. As the disease becomes more prevalent in the United States, physicians are recognizing that even younger people—those in their 40s or 50s, or even younger—can be affected to the extent that they require hospitalization. At the time of the webinar on April 8, Dr. Criner described having three COVID-19 patients aged 19–21 in his care at Temple University Hospital.

Dr. Criner also described a 45-year-old patient seen at an outside center’s emergency room with minor COVID-19 symptoms. These included mild fever, some shortness of breath, and a cough. The patient was sent home, but a week later he presented at Temple University Hospital with ARDS requiring prone ventilation and intubation. He stayed in the hospital for approximately three weeks, and, fortunately, survived.

Diagnosis is challenging.

A major challenge facing the care team is making a rapid and accurate diagnosis of COVID-19. Using nasopharyngeal (NP) swabs for nuclear antigen extraction is problematic and has a significant false-negative rate. In the three weeks prior to April 9, Temple University Hospital treated 624 patients with COVID-19 disease. Yet, the hospital also saw a high percentage of patients with similar exposure risk and similar clinical severity of symptoms on CT whose NP swab did not detect COVID-19. If possible, patients who present with a classic COVID-19 profile on HRCT but negative-NP swab should be treated the same as patients with a positive-NP swab—they should not be sent home or removed from respiratory isolation.

This diagnostic problem must be addressed with more precise and rapid testing; diagnosis is needed within 5 to 15 minutes.

Many patients present with severe symptoms.

The first 110 COVID-19 patients treated at Temple were classified into clinical severity stages based on clinical radiographic and hemo-cardio-respiratory parameters. Approximately 80% of successfully staged patients had either severe or very severe disease on presentation at Temple University Hospital, requiring high-end respiratory care in the ICU to maintain their survival.

  • Stage III (severe) disease includes a fever higher than 101°F; peripheral consolidation or ground glass opacity at the lobar level; and blood oxygenation higher than 40%. Patients should receive respiratory support via high-flow nasal therapy or BIPAP, and one low-level vasopressor for hemodynamic support.
  • Stage IV (very severe) disease includes hypotension, with SBP < 90mmHg; CT/HRCT showing diffuse infiltrates and ARDS. Patient requires intubation and positive-pressure ventilation (some require ECMO), as well as at least two vasopressors for hemodynamic support.

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Takeaways for Providers and Hospital Systems

  • Learn from colleagues in hot spots about how to prepare for an influx of patients who are sick with COVID-19 with high demand for respiratory care. Temple consulted with many physicians from China, New York City, and other areas in which the disease peak occurred earlier than in Philadelphia.
  • Policies and procedures must be put in place as early as possible to diagnose, treat, and prevent spread among the patient population you serve, but also among staff who are treating these patients.
  • COVID-19 will become the primary concern for any medical center in a cluster zone. You will need more than general hospital and ICU beds—if at all possible, a separate facility should be set aside for these patients, or an appropriate-sized section of the existing facility should be segregated to take care of COVID-19 patients. This includes patients with ICU needs as well as patients with milder symptoms.
    • Respiratory equipment: Intubation with PPV, as well as HFNT, BIPAP, and other forms of elite respiratory support are key for successful treatment of COVID-19 patients with severe disease.
    • PPE: Personal protective equipment for staff is of paramount concern and must be prioritized.
    • Care team: Providers should be organized in multidisciplinary teams; these team should not only include hospitalists, anesthesiologists, pulmonary and critical care specialists, radiologists, and infectious disease experts, but also cardiologists, rheumatologists, and even neurosurgeons to complement the base care team.
  • High-throughput testing and turnaround is crucial for proper COVID-19 care and preventing disease spread.
  • Because this is a fast-developing pandemic situation, clinical research is more important than ever to support and explore diagnostic and therapeutic options for this large number of very sick patients with high demand for care.

A note on triage for mechanical respiratory support.

Temple has implemented a triage protocol for ventilators that other facilities may find useful: when intubated patients have reached a level of stable ventilation, the high-end ventilator is removed and replaced with ventilators that have lower functional capacity. The more aggressive ventilation option is then used for patients who have a higher need for respiratory support.

Temple also has more than 100 OR and travel ventilators on reserve as well as home mechanical ventilators in preparation for the surge in cases in the coming weeks.

Although there has been a push for aggressive and early intubation to treat COVID-19, in Temple’s experience, intubation and PPV are needed only for approximately 14% of COVID-19 patients.

Others with severe disease can be managed with the judicious use of less-invasive options, such as HFNT or BIPAP. Combined with early treatment against cytokine storm, these less-invasive options can tide many patients through the tenuous early stages of the disease, and avoid the potential for increased morbidity that is always present for intubated patients.

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