Five important takeaways from recent COVID-19 recommendations
Several medical societies have issued recommendations for diagnosing and treating patients with COVID-19 in response to the pandemic.
Healio Primary Care asked experts for the top five takeaways from the recent guidance of the American College of Radiology (ACR), the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA).
Do not use chest X-rays or CT scans in place of viral testing
ACR recommends that chest X-rays or CT scans are not used in place of viral testing to diagnose COVID-19, unless access to or the turnaround time for viral testing is an obstacle.Ella A. Kazerooni MD, MS, chair of ACR’s thoracic imaging panel, explained that CT and chest X-ray images on patients with COVID-19 may “overlap” with other conditions.
“Some patients with COVID-19 have normal imaging studies,” she told Healio Primary Care. “Some patients have abnormal studies for which the findings cannot be distinguished from other conditions, including community-acquired pneumonia, influenza or even pulmonary edema and heart failure.”
Kazerooni, who is also a professor of radiology at the University of Michigan, added that the decision to quarantine patients with milder symptoms at home or to hospitalize patients solely on CT or chest X-ray results is not recommended.
‘Learning while doing’
Kevin C. Wilson, MD, chief of guidelines and documents at ATS, told Healio Primary Care that the most important takeaway from the ATS document is to collect data on patients with COVID-19 who receive one or more of the recommended interventions in “a manner that enables studies that use valid methods for causal inference and control of confounders.”
“There is very little direct evidence from patients with COVID-19,” he said. “Yet, we can’t simply wait for direct evidence to be published, we must take care of our COVID-19 patients now.”
Wilson continued, “we should use current treatments as an opportunity to learn since learning while doing through rigorous controlled observational research can be a next-best alternative while awaiting randomized trials when time is of the essence. We should collect data, assess the data periodically and adjust our practices accordingly.”
Use prone ventilation to improve oxygenation
Preliminary data indicate that two phenotypes of hypoxemic respiratory failure have emerged in patients with COVID-19, according to Wilson. The first phenotype is similar to traditional acute respiratory distress syndrome with poor oxygenation. The second has poor oxygenation and preserved compliance.
“We have a lot of evidence about how to best manage the former, little is known about how to best manage the latter,” he said.
Wilson, who is also professor of medicine at the Boston University School of Medicine, noted that “anecdotal evidence” supports using prone ventilation to improve oxygenation in patients with refractory hypoxemia due to progressive COVID-19 pneumonia, such as acute respiratory distress syndrome.
‘Find out what works, what does not’
The FDA recently authorized emergency use of the antiviral remdesivir for adults and children in the United States who are hospitalized with severe cases of COVID-19. National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD, said data from a multinational randomized controlled trial showed that Gilead’s investigational antiviral “has a clear-cut significant positive effect in diminishing time to recovery” for patients with COVID-19.
IDSA guideline panelist Rajesh T. Gandhi, MD, said the evidence supporting other therapies like hydroxychloroquine alone or in combination with azithromycin; lopinavir/ritonavir; tocilizumab; and convalescent plasma is uncertain. These agents should be evaluated in clinical trials to “find out what works and what does not,” he noted.
Wilson said that while randomized clinical trials for potential treatments are preferred, they are not always timely during a pandemic.
“The worst of the pandemic may have passed before COVID-19 related clinical trial results are published and, even then, there is no guarantee that the clinical trials will be definitive. Sometimes you must act based upon indirect evidence and clinical observations until the trial results become available,” he said.
However, in the absence of definitive treatments, supportive care can help many patients recover from COVID-19, Gandhi, who is an infectious diseases physician at Massachusetts General Hospital and a professor at Harvard Medical School, explained.
“Hydration, analgesics, oxygen supplementation and mechanical ventilation (if needed) can make an amazing difference,” he said.
Pandemic requires flexibility
ACR and ATS both stress the importance of physicians being flexible during the pandemic.
“We want to emphasize that knowledge of this new condition is rapidly evolving, and not all of the published and publicly available information is complete or up-to-date,” the authors of the ACR recommendations wrote. – by Janel Miller
ACR. ACR recommendations for the use of chest radiography and computed tomography (CT) for suspected COVID-19 infection. https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection. Accessed May 4, 2020.
ATS. ATS publishes new guidance on COVID-19 management. https://www.thoracic.org/about/newsroom/press-releases/journal/2020/ats-publishes-new-guidance-on-covid-19-management.php. Accessed May 4, 2020.
IDSA. Infectious Diseases Society of America guidelines on the treatment and management of patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/. Accessed May 4, 2020.
Disclosures: Gandhi reports serving as a member of a scientific advisory board for Merck. Kazerooni reports no relevant financial disclosures. Healio Primary Care could not confirm Wilson’s relevant financial disclosures at the time of publication.