Recognising the deteriorating respiratory patient in the context of the COVID-19 pandemic

Recognising the deteriorating respiratory patient in the context of the COVID-19 pandemic

Apr 1, 2020 0
COVID-19,Emergency Medicine,onthepods,respiratory
Summary Writer  Eloise Sobels

Anna McLean chats to Laura Glenn about how to recognise and manage a deteriorating COVID-19 positive patient.

Script Writer:  Anna McLean and Laura Glenn

Editor:  Laura Glenn

Interviewer:  Anna McLean

Interviewee:  Laura Glenn

About Dr Anna McLean

Dr Anna McLean is a Respiratory and Sleep Advanced Trainee at Royal Prince Alfred Hospital, Australia. She is a Clinical Lecturer with the University of Sydney and has had a long-standing interest in the medical education and pastoral care of both medical students and junior medical officers.

About Dr Laura Glenn

Dr Laura Glenn is a final year Advanced Trainee in Respiratory Medicine and is also undertaking a PhD with The University of Sydney in the field of interstitial lung disease. She has a strong interest in education and clinical leadership, and is an Associate Clinical Lecturer with The University of Sydney Medical School.

Recognising the deteriorating respiratory patient in the context of the COVID-19 pandemic

With Dr. Anna McLean and Dr. Laura Glenn, Respiratory Registrars at the Royal Prince Alfred Hospital, New South Wales, Australia.

Introduction

COVID-19 is a respiratory tract infection caused by the newly emergent coronavirus. This was first recognised in Wuhan, China in December 2019. While most people with COVID-19 develop mild or uncomplicated illness, approximately 14% will develop severe disease and that requires hospitalisation and oxygen support; and 5% will require ICU admission. Identifying those with severe or worsening symptoms early allows us to optimise supportive care and enables safe, rapid referral to appropriate management areas such as ICU.

This podcast goes through a real COVID-19 case (with some dramatic licence) with a particular focus on recognising signs of deterioration as well as appropriate investigations and management steps.

Case

A 44-year-old male presented to ED with a 1-week history of fevers and rigors associated with dyspnoea, lethargy, and anorexia. He had no significant past medical history and was on no regular medications. On initial examination, he was saturating at 99% on room air with a respiratory rate of 18/minute. His blood pressure was 120/80mmHg and his heart rate was 87bpm. A chest x-ray, bloods, and COVID-19 swab were performed, and he was admitted to the ward. You are called by the nursing staff to see him as on routine observations he was noted to be saturating at 87% on room air and had a respiratory rate of 23/minute.

  • Basic ISBAR handover from the nurse
  • Patient’s vital signs
  • Has the patient had a COVID-19 swab and are these results known?
  • Has the patient had a not for resuscitation (NFR) status documented and is this in the notes?
  • What basic investigations or interventions can be implemented prior to my arrival?
    • Supplemental oxygen
    • ECG
    • IV Fluids
  • Corridor thoughts on way to patient:
    • COVID-19 has a high transmission rate?personal protective equipment (PPE) is essential
    • Risk factors for COVID-19 positivity:
      • History of travel 
      • Exposure to known cases of COVID-19
    • Risk factors for more severe disease:
      • Older age
      • Comorbidities 
    • How far along is the patient on the COVID-19 disease trajectory?
      • Trends of deterioration in the second week of illness
  • There may be more than one process occurring particularly in older patients with comorbidities who are prone to cardiac and other complications of infection and treatment.
  • Complications of COVID-19 and associated syndromes:
    • Mild illness versus progressive pneumonia 
    • Acute respiratory distress syndrome (ARDS)
    • Superimposed bacterial infection with sepsis +/- septic shock 
    • Possible associated cardiomyopathy 
  • Other:
    • Acute pulmonary oedema
    • Tachy-arrhythmias, example, AF
    • Exacerbation of underlying comorbidities – COPD, asthma
    • Metabolic acidosis due to renal failure or sepsis 
    • Hospital-acquired pneumonia (HAP), aspiration pneumonia
    • Post-op patients: atelectasis, pulmonary embolism
  • Brief file review before entering the room of the patient:
    • Assessing patient demographics, age, past medical history (comorbidities)
    • Confirm if NFR documentation has been recorded in the notes
  • Apply PPE and have a buddy check to ensure that I have applied the PPE in the correct way.
  • End of the bed assessment:
    • Level of consciousness
    • Airway
    • Breathing: 
      • Using accessory muscles?
      • Tripoding? 
      • Intercostal recession?
    • Vital signs: 
      • Respiratory rate
        • Tachypnoea is the earliest and most sensitive sign of deterioration 
      • Oxygen saturations
  • Should I escalate or call for help immediately?
    • Are there any vital signs in the red zone?
    • Are there any immediate threats to life or am I concerned that this patient is deteriorating rapidly?
  • If not, I would conduct a more focused respiratory examination to nail-down a diagnosis
  • Assess level of consciousness, positioning and evidence of use of accessory muscles of respiration as above
  • Also: cyanosis, asterixis
  • Auscultation of chest:
    • Crackles (uni-lateral or bi-lateral): infection, heart failure
    • Bronchial breath sounds: consolidation
    • Wheeze: airways disease
    • Reduced air entry (+ altered percussion note): pleural effusion, pneumothorax
  • Additional signs:
    • Jugular venous pressure
    • Peripheral oedema

You assess the patient: his respiratory rate is 23/minute, he is saturating at 92% on 4L/minute nasal prong oxygen, his blood pressure is 130/80mmHg, his heart rate is 94bpm and his temperature is 37.6oC. The patient is alert and orientated, but he is using his accessory muscles of respiration. On auscultation of the chest, you hear bi-basal crackles but there are no other clinical signs of heart failure.

  • Immediate management:
    • Monitor patient’s oxygen saturations with pulse oximeter
    • Titrate supplemental oxygen accordingly:
      • Uptitrate the FiO2 by increasing the flow rate of oxygen via nasal prongs to 5L/min as required to maintain oxygen saturation levels above 90%
      • A Hudson mask would be required to administer higher flow rates of oxygen
    • If the patient has wheeze and you think they would benefit from bronchodilators, do NOT use any nebulised treatments due to risk of increasing aerosolisation of virus
    • High flow nasal prong oxygen should not be used in the management of a patient with suspected or confirmed COVID-19 without consultation with a senior due to the risk of aerosolisation and infection of staff and other patients
  • Investigations:
    • Review blood tests:
      • Full blood count
      • Biochemistry – renal function, liver function tests
      • Inflammatory markers (CRP)
      • Prognostic markers in COVID-19: LDH, D-dimer
      • Coagulation studies
    • Repeat ECG +/- additional cardiac investigations (troponin)
    • ABG if indicated
    • Repeat chest x-ray

You review the results of initial investigations: the white cell count is normal with a mild lymphopenia, the CRP is elevated at 89mg/L, liver function tests are mildly deranged with a transaminitis and the ABG reveals pH 7.44, PaO2 63mmHg and PaCO2 35mmHg. The chest x-ray shows bibasal interstitial opacities.

  • Importantly, oxygen should never be removed from a hypoxic patient in order to assess their PaO2–this is not safe!
  • When to perform an ABG:
    • If the patient is deteriorating and you are concerned about adequacy of ventilation
    • If the patient is prone to hypercapnia – to assess for evidence of type II respiratory failure
    • If the patient is requiring ventilatory support (example invasive ventilation) – to monitor progress (in ICU setting)
  • In this patient, I performed the ABG due to his clinical deterioration and evidence of worsening respiratory status to assess for evolving respiratory failure.
  • Interpreting an ABG:
  • pH – is there an acidosis? – Indicated by a  pH<7.35
  • PaCO2 – is it a respiratory acidosis? (versus metabolic). Indicated by a pCO2 >45mmHg
  • PaO2–determines the patient’s oxygenation:Hypoxaemia is defined by PaO2<80mmHg
    • Mild <80mmHg
    • Moderate <70mmHg
    • Severe <60mmHg
    • Elevated lactate can suggest inadequate perfusion (as seen in septic shock)
  • This patient has moderate hypoxaemia despite 4L/min of supplemental oxygen. There is no evidence of hypercapnia or acid-base disturbance
  • Are the changes consistent with COVID-19?
    • Viral pneumonitis: patchy unilateral or bilateral opacity, interstitial change?
    • ARDS: diffuse bilateral coalescent opacities (clinically associated with hypoxic respiratory failure)?
  • Is there any progression since the patient’s prior chest x-ray?
  • Are there any changes to suggest superimposed processes, or alternative diagnoses?
    • Lobar pneumonia – dense consolidation involving 1 or more lobes
    • Fluid overload – upper lobe diversion, Kerley B lines, pleural effusion(s)
  • The patient has deteriorated since initial review in the Emergency Department – need to inform rest of team +/- ICU
  • No specific therapy indicated at this stage aside from supplemental oxygen:
    • The chest x-ray demonstrates changes of viral pneumonitis or early ARDS.
    • The patient is hypoxic with bibasal crackles consistent with worsening COVID-19, but there are no clinical or radiological signs of alternate diagnoses or superimposed problems
  • Hence, would not give bronchodilators, steroids, Lasix or other medications at present (but would consider if the correct clinical indication was present)
  • I would document a plan for monitoring in the notes and ensure this was handed over to both the nursing staff looking after the patient and to my team
  • WHO guidelines: antibiotics should be prescribed when there is co-existing bacterial infection, especially if there is evidence of sepsis/septic shock.
  • Empiric treatment should be based off clinical diagnosis, e.g. treat as for provisional diagnosis:
    • Community acquired pneumonia
    • Hospital acquired pneumonia
    • Urinary tract infection
  • In this patient, the viral swab result is still pending. He’s got a fever, elevated inflammatory markers and CXR changes, I would prescribe antibiotics at this stage in case superimposed bacterial infection was contributing to his deterioration.

The patient continues to feel more breathless and you are no longer able to maintain the patient’s oxygen saturations >90% despite administering 8L/minute oxygen via a Hudson mask.

  • I’m now concerned this patient is too unwell to stay on the ward and is at high risk of continued deterioration. I think he will require ICU level care
  • The most important thing here to remember is to call for help and to call for help early if you’re concerned the patient is deteriorating
  • Remember DRSABCD approach to assessment and management of a patient and bear in mind your hospital specific basic or advanced life support (BLS/ALS) protocols
  • Continue to monitor the patient closely and initiate any appropriate empiric therapies whilst waiting for help
  • The general principles of bedside clinical assessment and recognition of a deteriorating patient have not changed because of the pandemic
  • First priority is to protect yourself and your co-workers. This involves knowing the patient’s COVID-19 status, wearing PPE as per protocol, minimising unnecessary contact with the patient and numbers of staff in the room and remembering no aerosol generating procedures should be performed without senior consultation
  • Escalate early if you’re concerned
  • If you’re worried or don’t know what to do, know who to call and how to call them. We are all here to help, and the most effective and safe approach will be for everyone to work together

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Tags: #Antibiotics,#coronavirus,#COVID-19,#deteriorating COVID-19 patient,#deteriorating respiratory patient,#dyspnoea,#infectious disease,#oxygen therapy,#pandemic,#personal protective equipment,#pneumonia,#respiratory,#respiratory and sleep medicine,#SOB

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