COVID-19 Respiratory Failure Treatment

For inpatient treatment of COVID-19 pneumonia with acute respiratory failure (aka, people with a positive COVID-19 test who need oxygen to keep their SPO2 > 92%).

Oxygen therapy levels

  1. Titrate oxygen for SPO2 > 92%
  2. Oxygen delivery modalities, stepwise:

↑↑↑ Less oxygen delivered ↑↑↑

  • Simple face-mask (avoid)
  • Non-Rebreather (face-mask with bag, also avoid)
  • Nasal cannula
  • Venturi Mask / Oxymask
  • High-Flow Nasal Cannula
  • BiPAP
  • Intubation & Ventilator

↓↓↓ More oxygen delivered ↓↓↓

Non-medication adjuncts

  1. Incentive spirometry (IS) at bedside (how to use IS)
  2. Encourage patients to “self-prone” by changing position every 30 minutes, choosing between sitting up, left side, back, right side, stomach.  (Note: Qian et. al 2022 [PDF]suggests that self-proning in non-intubated patients may not confer benefit.)

For all patients requiring oxygen (respiratory failure)

  1. Dexamethasone 6 mg IV or PO q24 hours for 10 days
  2. Remdesivir 200 mg IV x 1, then 100mg IV q24 hours for 5 days, or

For high risk patients, or anybody that acutely worsens

It is not yet clear whether baricitinib or tocilizumab is superior. Choice depends mostly on availability and institutional practice.

  1. An anti-inflammatory medication, either:
  • Baricitinib 4 mg PO for 14 days, or
  • Tocilizumab 8mg/kg (weight >= 30kg) or 12mg/kg (weight < 30kg) IV infusion x 1 (max dose 800 mg)

If bacterial pneumonia suspected

2-3% of COVID-19 pneumonia patients also develop bacterial pneumonia.

  1. Ceftriaxone 2 gm IV q24 hours x 5 days,
  2. Plus pick one:
  • Usually: Azithromycin 500 mg IV q24 hours x 5 days, or
  • If concern for MRSA: Doxycycline 200 mg IV x 1, then 100 mg IV q12 hours for 10 days

For symptom relief

  1. Tessalon perles (aka benzonatate) PRN cough
  2. Guaifenesin (with or without codeine) PRN cough
  3. Ipratropium-albuterol nebulizer treatments PRN shortness of breath
  4. Acetaminophen PRN pain/fever/headache

DVT prophylaxis

  1. Pick your favorite prophylaxis:
  • Lovenox 30-40 mg SQ q24 hours (normal prophylactic dose, adjusted for renal function if necessary), or
  • If kidney injury: Heparin 10K units q8-12 hours

NIH COVID-19 Hospitalized Patient Management

Feature Image attribution: CDC PHIL #23354, downloaded on 3/14/2022