Diese Präsentation wurde erfolgreich gemeldet.
Wir verwenden Ihre LinkedIn Profilangaben und Informationen zu Ihren Aktivitäten, um Anzeigen zu personalisieren und Ihnen relevantere Inhalte anzuzeigen. Sie können Ihre Anzeigeneinstellungen jederzeit ändern.

COVID 19- Diagnosis and Treatment

965 Aufrufe

Veröffentlicht am

Approach towards COVID 19

Veröffentlicht in: Gesundheit & Medizin
  • Prevention of Coronavirus How to Bolster Your Immune System? All Natural Immune Boosters Proven To Fight Infection, Disease And More...Discover A Natural, Safe & Effective Way To Boost Your Immune System Using Ingredients From Your Kitchen Cupboard...The only common sense, no holds barred guide to hit the market today… no gimmicks, no pills, just old fashioned common sense remedies to prevent coronavirus and cure colds, influenza, viral infections and more...Imagine what your life would be like if you could boost your immune system a safe and natural way using products you already have in your cupboard... would you be interested?Of course! Any time of the year is a good time to fight infection.Are you one of the millions of people that suffer from chronic colds, the flu, allergies and other common infections leading to poor health? Or are you search how to boost your immune system so you can protect yourself and your family from the Coronavirus (COVID-19)? If so, what I am about to tell you will change the way you look at your body and your health forever.For years I've struggled with poor health. As a child I had more than my share of antibiotics, some worked and some did not.Bacteria Are Becoming Smarter, And No Longer Responding To Traditional Antibiotics… What Are YOU Going To Do About It?It's true. For years doctors prescribed antibiotics for everything from the common cold to headaches. Here's a fact. Antibiotics do NOT work on viruses. They will not clear up your cold.Unless you have a bacterial infection, antibiotics are worthless. And, the more you take, the less likely they are to work on future infections.Super Bugs Are Here… You Have A Limited Time To Learn Natural Ways To Boost Your Immune System, Before It’s Too Late...We live in an age where hard to cure infections are common. People are dying from diseases like Coronavirus, SARS-CoV-2 and staph that used to be easily treated with ordinary antibiotics. This is no longer the case.What can you do about it? Learn everything there is to know about boosting your immune system. When you work to prevent illness and boost your immune system, you have a much better chance of fighting off infection, even if you do develop a severe infection that is hard to treat.BUT, to fight infection you must first understand how to boost your immune system. Here's how...you can get COVID-19 Bolster Your Immune System with 5 free bonus by https://fitness2u.club/preventing-coronavirus/
    Sind Sie sicher, dass Sie …  Ja  Nein
    Ihre Nachricht erscheint hier

COVID 19- Diagnosis and Treatment

  1. 1. COVID 19 –Diagnosis & Treatment Dr Rohit Kallukadavil MBBS, MD, DNB, MRCP Sce (Resp) Consultant Pulmonologist and Critical care specialist HGM Hospital, Kottayam, Kerala.
  2. 2. Introduction • COVID 19- caused by SARS CoV-2 • World wide 37L pts infected and 2.6L patients died • Till now there is no specific treatment or vaccinations available.
  3. 3. Pathophysiology Virus particle emerging from cell
  4. 4. Stages of Infection Stage I- Mild (Early Infection): • Local symptoms-throat irritation, dry cough, fever etc. Many asymptomatic. Pt vl be infective. 80% recover in few weeks. • Lymphopenia & neutrophilia.
  5. 5. Stage II- Moderate Disease /Pulmonary phase: • Viral multiplications, Infect lung- epithelial injury – DAD – ARDS- hypoxemia. • Blood- lymphopenia. Transminitis. Procal- Normal • Need hospitalisation.
  6. 6. Stage III- severe (Inflammatory response): • Extrapulmonary systemic hyperinflammation. Decrease T cells. • cytokine storm – IL6,IL2, IL7,TNF alpha , CRP,D dimer, Ferrititn, Trop, BNP: progress to– MODS • myocarditis • Rx: steroids, IL -6 inhibitors
  7. 7. Lung phenotypes Type L patient- Low elastance, Low V/Q, low lung weight, Low recruitability • severely hypoxic without significant dyspnoea(silent hypoxemia). • Better response to O2, may not benefit from high PEEP. Type H patient (30%) – High elastance, R-L shunt, high lung weight, High recruitability- • Histopathology- typical DAD • May need Invasive ventilation Ref: COVID-19 pneumonia: different respiratory treatments for different phenotypes? Luciano Gattinoni, Intensive Care Medicine (2020)
  8. 8. Other organs • Heart – elevated Trop/BNP- ? Left ventricular dysfunction, myocarditis • Kidney- 4.5% pts, ? Due to cardiac failure, sepsis, fluid dysregulation, rhabdomyolysis etc • Neurological- ? CVA.
  9. 9. Vascular Injury • SARS CoV2 bind to ACE receptors in Endothelial cells of blood vessels-injury and cytokine- thrombosis • Resp failure not explained with ARDS alone- microvascular thrombotic process also • Strong association between D Dimer, disease progression and CT features of venous thrombosis • Autopsies showed thrombosis in multiple organs • IL 6 elevation after 13 days of disease onset, but D –Dimer level 10 fold raised before that.
  10. 10. • Prophylactic and therapeutic anticoagulation showed better out comes • CT – vessel enlargement near areas of GGO-in 89% pts • CTPA – 40% subsegmental embolism
  11. 11. Recommendations- Dutch health care
  12. 12. Children safe from Covid ? • Less viral load • ACE 2 expression is lower • Poorly developed humoral and cellular immune system • Recurrent antigenic stimuli from viruses cause more inflammatory immune response in adults
  13. 13. Diagnosis
  14. 14. Covid suspect: • All symptomatic(fever, cough and Dyspnoea) individuals who have undertaken international travel in the last 14 days • or • All symptomatic contacts of laboratory confirmed cases • or • All symptomatic healthcare personnel (HCP) • or • Hospitalized patients with fever AND cough and/or shortness of breath • or • Asymptomatic direct and high risk contacts of a confirmed case (should be tested once between day 5 and day 14 after contact) • Symptomatic pts in Hotspots/cluster (as per MoHFW) and in large migration gatherings/evacuees centres: Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms
  15. 15. Samples for analysis Specimen Positivity BAL 93% Sputum 72% Nasopharyngeal swab 63% Oropharyngeal swab 32% Faeces 29% Blood 1% Urine 0% Detection of SARS-CoV-2 in different types of clinical specimens. Wenling Wang, Yanli Xu. JAMA.2020. Mar11 Preferred: Throat & nasal swab
  16. 16. Diagnostic Test • RT- PCR(Reverse transcriptase polymerase chain reaction) • Gold standard for diagnosis(100% specificity) • Positive result in early phase, later can be –ve due to immunity devlopment. • Expensive, time consuming(6-8 Hr), low sensitivity(50- 70%)
  17. 17. Sample – treated with chemicals- Extract RNA – Reverse transcribed to DNA – Add a complimentary DNA fragment to detect Corona virus- If virus is present, it will attach to the fragment- fluorescent material also added for labelling— RT PCR machine- each cycle double the DNAA- 35 cycles minimum- machine detect florescence- in real time manor.
  18. 18. • If RT PCR is negative and suspicion is high – test should be repeated- if possibly from lower resp tract • Positivity rates >90% on Day 1-3 of ilnness, <80= at Day6, <50% after day 14.
  19. 19. Rapid antibody tests • ELIZA test- IgM(active infection) and IgG(Past infection) • Can be used as a screen test • Point of care test, rapid results • cheaper • Blood test • Combined IgG+IgM – better utility
  20. 20. Disadvantages: • Negative in early phase • Specificity is low ? • Cross sensitivity to other corona viruses.
  21. 21. • Biosecurity precautions- collection of samples • Only RT PCR(No conventional PCR or Antibody test) • Positive samples- to be transported to ICMR- NIV • Truenat machine – can also be used.
  22. 22. Treatment There are no sp antiviral drugs or vaccines available at present
  23. 23. • All health care providers should take extra precautions – Mask, gloves, PPEs etc • Social distancing • Avoiding unnecessary crowds in hospitals(amplifyng centre for a pandemic) • Isolate suspects and +ve pts in Covid care centres • Only <20% require admission/ ICU care • Ideal to have Neg pressure Isolation room
  24. 24. Categories A Mild sore throat/ cough/ rhinitis/ diarrhea B Fever and /or severe sore throat/ cough / diarrhea or Cat A + Any of the following Cardiovascular disease Uncontrolled DM, HTN, Cancer, HIV, lung, liver, renal or neurological diseases On steroids/ immunosuppressants Pregnancy Age> 60 yrs C Dyspnoea, chest pain, drowsy, low BP, cyanosis, haemoptysis Children with ILI Worsening of underlying chronic conditions
  25. 25. High risk patients • age>60, With comorbidities • spo2<93%, HR>125, RR>30, BP<90/60 • Altered sensorium • CRP>100, CPK> two time upper limit • Ferritin >300, LDH>245, D- dimer>1000, Trop T +ve • MODS
  26. 26. Admission • Covid care centre: Confirmed mild cases • Covid Ward: High risk patients, Category B pts RR>24 Spo2<94% • Covid ICU: Category C patients Moderate – severe ARDS MODS Shock
  27. 27. Treatment • A,B,C categories • Only Paracetamol, avoid other NSAIDs • All ILI- use oseltamivir till COVID result available • Broad spectrum antibiotics • Better avoid steroids
  28. 28. Treatment A Symptomatic Rx Reassess and categorize Q 28-48Hrs B HCQ 400mcg BDx 1day, 200mg BD x4 days Or Chloroquine600mg then 300mg BD x 5 days + Tab Azithromycin 500mg OD x 5 days. Oseltamivir 75mg BD x 5 days in all ILI until PCR reports C All ILI- Oseltamivir HCQ/Chloroquine + Inj Azithromycin Tab Lopinavir/Ritonavir(400/100) x 14 days (If HCQ contraindicated/ on compassionate use with consent, has to be started within 10 days of symptom onset) If ARDS /MODS- add Lopinavir/ ritonavir and stop Azithromycin(QTc monitor)
  29. 29. Cytokine release syndrome • Grade1: Mild fever • Grade 2: High fever, mild O2 requirement, Raised creat/ LFT • Grade 3: B/L lung infiltrates, SPo2<93%, Raised LFT,INR>1.5, encephalopathy, AKI, hypotension, coagulopathy • Grade 4: Life threatening MODS, hypoxia requiring ventilation, hypotension requiring high vasopressors.
  30. 30. • Serum IL-6 is the marker, ferritin • CRP- surrogate marker • Grade 3& 4- use Tocilizumab 8mg/kg IV (max 800mg) over 60min, if no effect repeat x 2 more doses Q8H. • If no response corticosteroids.
  31. 31. Steroids in COVID • Better to avoid • Delays viral clearance • Use in • Refractory shock, Macrophage activation syndrome, cytokine release syndrome Grade 3/ 4 • 1-2mg/kg /day methylprednisolone equivalent x 3-5 days
  32. 32. Chloroquine/HCQ • Change Ph of endosome and viral entry • No renal or hepatic dose adjustement • 400mg BDx 1, then 200mg BD x 4 days. • HCQ is more potent antiviral than chloroquire • Side effect: QT prolongation, ventricular arrhythmias • Contraindications: QTc>500msec, Porphyria, Myasthenia, Retinopathy, Epilepsy
  33. 33. Evidence • Cause Increase Ph of endosome and prevents virus entry, transport and post entry events ? • invitro action- chloroquine/ hcq against viruses- corona/ influenzea • No peer reviewed publications/ well conducted RCT. • Unpublished study from China and France(HCQ+ Azithromycin) – showed better viral clearance.
  34. 34. Conclusion – This study therefore recommends that COVID-19 patients be treated with hydroxychloroquine and azithromycin to cure their infection and to limit the transmission of the virus to other people, Figure - Percentage of patients with PCR-positive nasopharyngeal samples from inclusion to day6 post-inclusion in COVID-19 patients treated with hydroxychloroquine only, in COVID-19 patients treated with hydroxychloroquine and azithomycin combination, and in COVID-19 control patients Ref – Int J Antimicrob Agents. 2020 Mar 20 : 105949 Biosci Trends. 2020 Apr 5. doi: 10.5582/bst.2020.03058.
  35. 35. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: an observational study • In 80 in-patients receiving a combination of hydroxychloroquine and azithromycin • A rapid fall of nasopharyngeal viral load tested by qPCR was noted, with 83% negative at Day 7, and 93% at Day 8. • Virus cultures from patient respiratory samples were negative in 97.5% patients at Day 5. • This allowed patients to rapidly discharge from highly contagious wards with a mean length of stay of five days.
  36. 36. Remdesivir • In vitro activity against SARS Cov2 • Premature termination of RNA transcription • Only for compassionate use • Interim analysis of RCT in US- faster recovery • Chinese study- No significant recovery or mortality benefits • 200mg IV then 100mg IV OD x 9 days • Side effects: GI intolerance/ hepatotoxicity.
  37. 37. 2nd SIMPLE Trial
  38. 38. Lopinavir/Ritonavir • WHO – drug can be tried • CYP3A4 inhibitor- monitor drug interactions • QT prolongation, hepatotoxicity. Interferons • IFN-2a, IFN-2b orIFN-1a • Side effect: Flu like syndrome
  39. 39. Tocilizumab • IL-6 inhibitor • Reduce cytokine storm • Adverse effects: Hepatitis, can worsen other infections
  40. 40. Solidarity trial COVID Remdesivir Chloroquine/HCQ Lopinavir+Ritonavir Lop/Ritonavir + Interferon B-1a Standard Rx • WHO supported Phase III-IV trial • From 18/3/2020 – started • >100 countries • COVID pt >18 year age. Similar RCT, resp failure pts in Europe- DISCOVERY trial, March 2020 to March 2023
  41. 41. Convalescent plasma • Plasma from recovered pts • Efficiency not known • One study- improved viral clearance and oxygenation by 12 days after transfusion • Another- 5/6 pt died within 3 days despite viral clearance • Dose: 10-15mL/kg • Need high titre of neutralizing antibody • Lack of infectious particles • ABO and Rh compatible
  42. 42. Side effects: • Infections • Volume overload • Febrile and allergic reactions • Anaphylaxis(In IgA deficiency) • TRALI
  43. 43. Ivermectin • Antiparasite drug • Inhibit entry of viral protein into nucleus of cell • In vitro studies-Australia showed : single treatment able to effect 5000 fold reduction in virus at 48 hour in cell culture.
  44. 44. ? Traditional Chinese Medicines • TCM- used for long time • Effective component- unknown or vague • Chinese studies- WM+TCM Vs WM: symptomatic worsening= 7.4% Vs 46.2%, Mortality 8.8%Vs39%
  45. 45. Supportive therapy • Supplemental oxygen- in hypoxia or shock • Target SpO2 ≥90% , pregnant ≥92-95 % • Conservative fluid- in SARI without shock, aggressive fluid Mx can worsen oxygenation • Antimicrobial within 1 hr of identification of sepsis
  46. 46. Hypoxia • If supplemental oxygen cannot alleviate symptoms- use NIV/HFNO. • NIV – proper interface and PPE reduce chance of transmission • Intubation produce more aerosol and chance of viral transmission
  47. 47. Mechanical ventilation • Severe resp failure- intubate and ventilate • Use new tubings and viral filtres • Low tidal volume, high PEEP strategy • Prone ventilation/ ECMO
  48. 48. Septic shock Mx • Use crystalloids (NS/RL) with caution • If no response to fluid vasopressor • Central line or peripheral line • Target MAP >65, urine out put > 0.5ml/kg/hr
  49. 49. Prone positioning Awake proning: • Adjunct to use of NIV- as a rescue therapy before intubation • Based of perfusion redistribution • Benefits are short lived • Consider- if pt can communicate & co operate if pt able to rotate and adjust position • Pt should switch positons every 30min to 2 hours Proning after intubation- follow standard protocols.
  50. 50. Prevention of the transmission of infection • droplet precaution (e.g. wearing mask & PPE), contact precaution (e.g. hand washing or wearing gloves and gown) and airborne precaution (e.g. isolation room with negative pressure) • The use of clinical triage for the early identification of patients with ARI • Isolation or cohorting of patients to prevent the transmission • Use of PPE and adequately ventilated single rooms when performing aerosol generating procedures ‘One Health’ approach communication and collaboration between countries to build trust and academics IPC, infection prevention and control; ARI - acute respiratory Infection; PPE, Personal Protective Equipment Park S, Park J, Song Y, How S, Jung K. Respirology. 2019;24(6):590-7.
  51. 51. Prevention of complications- critically ill pts • Use weaning protocols – daily • Daily interruption of continuous sedation • Semi recumbent position • Closed suctioning • New ventilator circuit for each pt • DVT prophylaxis • Turn pt Q2Hr to reduce bed sores • Early enteral nutrition • Ulcer prophylaxis • Mobilize of limb physiotherapy
  52. 52. Outcomes Variable Number % Total 305 Median Hosp days 8.5 O2 76% NIV 3.6% HFNO 22% ICU 39% Median ICU days 8 MV 30% RRT 7.5% Inotrope 27.5% Death 17% Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 — Georgia, March 2020 New york April 14
  53. 53. Viral clearance • Repeat RT PCR should be done every 2 to 4 days- until 2 consecutive results are negative (URT samples) – 24 Hr apart. • Symptomatic pts- after the resolution of symptoms, samples should be collected at least seven days after the onset or after > 3 days without fever. • Asymptomatic infected persons, the tests should be done at a minimum of 14 days after the initial positive test. • Virus can persist 7-12 days in moderate & 2 wks in severe cases • Prolonged viral shedding in some, > 2 wks to months in PCR, but cultures – negative • Wuhan study Mean duration of viral shedding- 20 days, longest : 37 days • 50% pts show viral shedding even after symptom resolution
  54. 54. Thank you