Abstract
BACKGROUND: The global pandemic of coronavirus disease 2019 (COVID-19) rapidly spread to 213 countries with majority of deaths caused by pneumonia. About 80% of COVID-19 infections have mild/asymptomatic disease but about 5% of comorbid patients become critically ill and develop acute respiratory distress syndrome (ARDS). ARDS develops in a median time of 8 to 12 days from illness onset and occurs more commonly in intensive care unit (ICU) patients with a 72% mortality rate. Based on the reports of higher mortality risk among mechanically ventilated patients, the standard approach and treatment protocol widely used in COVID-19 related ARDS needs to be adjusted. No definitive therapies or vaccines have been developed yet. Safety and efficacy of some antimalarial and antiviral drugs against severe acute respiratory syndrome coronavirus2(SARS-CoV-2) are still under clinical trials.
OBJECTIVE: To summarize the clinical presentation, laboratory and chest imaging findings, management protocols, and outcome and to find more data from established studies and treatment guidelines for high-risk and critical conditions like ARDS in COVID-19-positive patients to improve their survival and reduce mortality.
METHODS: Six case reports published in English from December 1. 2019 to April 12, 2020 were identified using the Medline database from the National Library of Medicine (NLM) and search strings: coronavirus disease (COVID-19) and acute respiratory distress syndrome (ARDS) and as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Two case reports were excluded but other four which met our systematic review criteria were included as outlined in the flow diagram below.
RESULTS: We studied six COVID- 19 patients ranging from 44 to 75 years with critical illness and/or ARDS. Most common initial presentation: Brief history of cough +/- fever, chills, dyspnea and fatigue. Chest x-ray and CT scan revealed bi-basilar ground-glass opacities in all six patients. Early treatment with antiviral agents like oseltamivir 75 mg BID and lopinavir/ritonavir 400/100 mg BID in one asymptomatic case lead to spontaneous resolution. Dyspnea and severe hypoxemia developed within 48-72 hours in remaining patients and by the second week, oxygen saturation (SaO2) declined requiring O2 supplementation or assisted ventilation. Antiretroviral protease inhibitors in three of total six cases either as lopinavir/ritonavir 500 mg BID +/-oseltamivir 400/100 mg BID showed marked improvement in the majority. Empiric broad-spectrum antibiotics such as moxifloxacin were effective in one of two mechanically ventilated patients. Antimalarials like hydroxychloroquine stat 400 mg given with either azithromycin or oseltamivir (75 mg) were used in four out of six cases of which one died. Corticosteroids, such as intravenous methylprednisone were administered in one patient who ultimately died. Use of tissue plasminogen activator (tPA) for COVID-19-associated ARDS in a case series resulted in a variable response.
CONCLUSION: Our systematic review of published cases of ARDS in COVID-19 positive patients will help healthcare professionals to clearly understand and implement updated treatment strategies and confront the COVID-19 pandemic and its medical consequences. More randomized controlled trials (RCT’s) are required to determine optimal dosing, therapeutic safety and efficacy of current treatment modalities.
