By Mary O’Brien, M.D.
Every new illness brings new knowledge. Global experience with COVID-19 is revealing patterns of clinical illness which will guide our approach to treatment. Here are some of those important observations:
- The illness in 80% of people causes mild symptoms. Many people remain completely asymptomatic. Moderate and severe illness often has two phases. Days 1‒7 are characterized by fever (above 101° F), headache, significant cough, profound fatigue, myalgias, and malaise. Between days 4‒8 some patients have nausea, vomiting, abdominal pain, and/or diarrhea. Some patients lose their sense of taste and smell. Days 8‒21 are characterized (in 15‒20% of patients) by increasingly severe symptoms, including shortness of breath, dyspnea or difficulty breathing, chest pain or tightness, tachycardia and weakness.
- The mean interval between onset of symptoms and hospitalization is 9.1‒12.5 days. This delay in the progression to serious illness may give us a window of opportunity for treatment.
- Clinical findings typically include a low oxygen saturation level (O2 sat) on room air. This is a key finding and levels as low as 75‒90% are being seen (95‒100% is normal).
- Laboratory results also show patterns similar to what was observed with SARS and MERS:
o ↓ WBC or leukopenia
o ↓ Platelet count or thrombocytopenia
o ↑ Liver enzymes, especially LDH around hospital days 5‒8
o CXR typically shows streaky opacities in both lungs consistent with an atypical pneumonia.
- Serious complications of COVID-19 include severe viral pneumonia, ARDS (Adult Respiratory Distress Syndrome) respiratory failure, cardiac injury including arrhythmias and CHF. Poor perfusion can lead to hepato-renal syndrome. Neurologic symptoms, delirium, and coma may occur.
- There is evidence that intubation and mechanical ventilation may be causing more harm than good in some patients. One component of ventilator function, the PEEP setting (positive end-expiratory pressure) may be delivering pressures that are too high for the alveoli or air sacs in the lungs. It appears that some COVID-19 patients in respiratory distress actually need lower levels of PEEP (15‒20) as opposed to levels around 25. Some patients seem to need higher O2 concentrations delivered by face mask, CPAP or BiPAP, and not intubation and mechanical ventilation.
- According to the CDC, two thirds of the patients who have died from COVID-19 (as of mid-April) had documented serious underlying conditions (heart disease, diabetes, asthma, renal disease, malignancy, immuno-compromise). Obesity has been a significant factor contributing to mortality. 1.9% of patients who have died had no known underlying condition.
We have only scratched the surface here. The next few weeks will reveal new insights about the illness itself and the best treatment protocols. In the meantime, do what is prudent to protect yourself and others. It may not be obvious to everyone, but tremendous progress is being made.
Blessings to all through Passover and Easter.