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Author: StJohn Piano
Published: 2020-04-25
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This article contains excerpts that I read during my research on home treatments for COVID-19.

COVID-19 is the disease caused by SARS-CoV-2, a novel coronavirus that emerged in late 2019 and developed into a global pandemic.









List of sources:




bda.uk.com
British Dietetic Association


bmj.com
British Medical Journal


weekly.chinacdc.cn
CCDC Weekly
[CCDC = Chinese Center for Disease Control and Prevention]


citizensadvice.org.uk
Citizens Advice service (UK)


healthline.com
Healthline Media


hse.ie
Health Service Executive (Ireland)


imperial.ac.uk
Imperial College London


livescience.com
LiveScience


lung.org
American Lung Association


mayoclinic.org
Mayo Clinic


medrxiv.org
medRxiv


nejm.org
New England Journal of Medicine


newscientist.com
NewScientist


sciencedaily.com
ScienceDaily


scientificamerican.com
Scientific American


telegraph.co.uk
The Telegraph


texags.com
TexAgs


thelancet.com
The Lancet


who.int
World Health Organization


www.cdc.gov
Centers for Disease Control and Prevention (USA)


www.nhlbi.nih.gov
National Heart, Lung, and Blood Institute (USA)


www.nhs.uk
National Health Service (UK)

















Excerpt from:
www.who.int/health-topics/coronavirus#tab=tab_1
Title: Coronavirus / Overview

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.







Excerpts from:
www.who.int/health-topics/coronavirus#tab=tab_3
Title: Coronavirus / Symptoms

COVID-19 is a respiratory disease and most infected people will develop mild to moderate symptoms and recover without requiring special treatment. People who have underlying medical conditions and those over 60 years old have a higher risk of developing severe disease and death.

Common symptoms include:

- fever
- tiredness
- dry cough

Other symptoms include:

- shortness of breath
- aches and pains
- sore throat
- and very few people will report diarrhoea, nausea or a runny nose.

[...]

People with fever, cough or difficulty breathing should call their doctor and seek medical attention.







Excerpts from:
www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963
Title: Coronavirus disease 2019 (COVID-19) / Symptoms & causes
Date: April 07, 2020

In 2019, a new coronavirus was identified as the cause of a disease outbreak in China.

The virus is now known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease it causes is called coronavirus disease 2019 (COVID-19). In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.

[...]

Symptoms

Signs and symptoms of COVID-19 may appear two to 14 days after exposure and can include:

- Fever
- Cough
- Shortness of breath or difficulty breathing

Other symptoms can include:

- Tiredness
- Aches
- Runny nose
- Sore throat

Some people have experienced the loss of smell or taste.

The severity of COVID-19 symptoms can range from very mild to severe. Some people may have no symptoms at all. People who are older or who have existing chronic medical conditions, such as heart disease, lung disease or diabetes, or who have compromised immune systems may be at higher risk of serious illness. This is similar to what is seen with other respiratory illnesses, such as influenza.

[...]

If you have emergency COVID-19 signs and symptoms, such as trouble breathing, chest pain or pressure, confusion, or blue lips or face, seek care immediately.

[...]

Although most people with COVID-19 have mild to moderate symptoms, the disease can cause severe medical complications and lead to death in some people. Older adults or people with existing chronic medical conditions are at greater risk of becoming seriously ill with COVID-19.

Complications can include:

- Pneumonia in both lungs
- Organ failure in several organs







Excerpt from:
www.mayoclinic.org/diseases-conditions/coronavirus/diagnosis-treatment/drc-20479976
Title: Coronavirus disease 2019 (COVID-19) / Diagnosis & treatment
Date: April 07, 2020

Treatment

Currently, no antiviral medication is recommended to treat COVID-19. Treatment is directed at relieving symptoms and may include:

- Pain relievers (ibuprofen or acetaminophen)
- Cough syrup or medication
- Rest
- Fluid intake

[...]

During this time, remember to take care of yourself and manage your stress.

- Eat healthy meals.
- Get enough sleep.
- Get physical activity as you're able to, such as using exercise or yoga videos. If you're healthy, go outside for a walk.
- Try relaxation exercises such as deep breathing, stretching and meditation.
- Avoid watching or reading too much news or spending too much time on social media.
- Connect with friends and family, such as with phone or video calls.
- Do activities you enjoy, such as reading a book or watching a funny movie.

If you're ill with COVID-19, it's especially important to:

- Get plenty of rest.
- Drink fluids.







Excerpt from:
www.cdc.gov/coronavirus/2019-ncov/faq.html
Title: Coronavirus Disease 2019 (COVID-19) - Frequently Asked Questions
Date: April 11, 2020

On February 11, 2020 the World Health Organization announced an official name for the disease that is causing the 2019 novel coronavirus outbreak, first identified in Wuhan, China. The name of this disease is coronavirus disease 2019, abbreviated as COVID-19. In COVID-19, 'CO' stands for 'corona,' 'VI' for 'virus,' and 'D' for disease. Formerly, this disease was referred to as "2019 novel coronavirus" or "2019-nCoV".

There are many types of human coronaviruses including some that commonly cause mild upper-respiratory tract illnesses. COVID-19 is a new disease, caused by a novel (or new) coronavirus that has not previously been seen in humans.







Excerpt from:
www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

Early information out of China, where COVID-19 first started, shows that some people are at higher risk of getting very sick from this illness. This includes:
- Older adults
- People who have serious chronic medical conditions like:
-- Heart disease
-- Diabetes
-- Lung disease







Notes from a conversation with a friend who contracted COVID-19 and spent a week in hospital.
- He was having a lot of trouble breathing, called an ambulance, and was transported to hospital.
- His treatment consisted of: Antibiotics, oxygen supply.
- He spent a week in hospital recovering.
- He recommended that another person in his position should ask for medical assistance more quickly than he did.






Excerpt from:
www.citizensadvice.org.uk/health/coronavirus-what-it-means-for-you
Title: Coronavirus - what it means for you
Date: 9 April 2020

You're 'extremely vulnerable' if you have certain medical conditions - for example, severe asthma or cancer.







Excerpt from:
www.nhs.uk/conditions/coronavirus-covid-19/symptoms-and-what-to-do
Date: 9 April 2020

Do not leave your home if you have either:

- a high temperature - this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
- a new, continuous cough - this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)







Excerpts from:
www.healthline.com/health/coronavirus-treatment
Title: Treatment for Coronavirus Disease (COVID-19)
Author: Aimee Eyvazzadeh, MD, MPH
Medically reviewed by Meredith Goodwin, MD, FAAFP
Date: March 12, 2020

What type of treatment is available for the novel coronavirus?

There currently isn't a vaccine against developing COVID-19. Antibiotics are also ineffective because COVID-19 is a viral infection and not bacterial.

If your symptoms are more severe, supportive treatments may be given by your doctor or at a hospital. This type of treatment may involve:

- fluids to reduce the risk of dehydration
- medication to reduce a fever
- supplemental oxygen in more severe cases

People who have a hard time breathing on their own due to COVID-19 may need a respirator.

[...]

Remdesivir is an experimental broad-spectrum antiviral drug originally designed to target Ebola.

Researchers have found that remdesivir is highly effective at fighting the novel coronavirus in isolated cellsTrusted Source.

This treatment is not yet approved in humans, but two clinical trials for this drug have been implemented in China. One clinical trial was recently also approved by the FDA in the United States.

[...]

Chloroquine is a drug that's used to fight malaria and autoimmune diseases. It's been in use for more than 70 years and is considered safe.

Researchers have discovered that this drug is effective at fighting the SARS-CoV-2 virus in studies done in test tubes.

At least 10 clinical trials are currently looking at the potential use of chloroquine as an option for combating the novel coronavirus.







Excerpts from:
www.who.int/news-room/q-a-detail/q-a-coronaviruses
Title: Q&A on coronaviruses (COVID-19)
Date: 8 April 2020

What are the symptoms of COVID-19?

The most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat or diarrhea. These symptoms are usually mild and begin gradually. Some people become infected but don't develop any symptoms and don't feel unwell. Most people (about 80%) recover from the disease without needing special treatment. Around 1 out of every 6 people who gets COVID-19 becomes seriously ill and develops difficulty breathing. Older people, and those with underlying medical problems like high blood pressure, heart problems or diabetes, are more likely to develop serious illness. People with fever, cough and difficulty breathing should seek medical attention.


[...]


Are antibiotics effective in preventing or treating the COVID-19?

No. Antibiotics do not work against viruses, they only work on bacterial infections. COVID-19 is caused by a virus, so antibiotics do not work. Antibiotics should not be used as a means of prevention or treatment of COVID-19. They should only be used as directed by a physician to treat a bacterial infection.







Excerpt from:
www.who.int/news-room/q-a-detail/q-a-similarities-and-differences-covid-19-and-influenza
Title: Q&A: Similarities and differences - COVID-19 and influenza
Date: 17 March 2020

As the COVID-19 outbreak continues to evolve, comparisons have been drawn to influenza. Both cause respiratory disease, yet there are important differences between the two viruses and how they spread. This has important implications for the public health measures that can be implemented to respond to each virus.




How are COVID-19 and influenza viruses similar?

Firstly, COVID-19 and influenza viruses have a similar disease presentation. That is, they both cause respiratory disease, which presents as a wide range of illness from asymptomatic or mild through to severe disease and death.

Secondly, both viruses are transmitted by contact, droplets and fomites. As a result, the same public health measures, such as hand hygiene and good respiratory etiquette (coughing into your elbow or into a tissue and immediately disposing of the tissue), are important actions all can take to prevent infection.




How are COVID-19 and influenza viruses different?

The speed of transmission is an important point of difference between the two viruses. Influenza has a shorter median incubation period (the time from infection to appearance of symptoms) and a shorter serial interval (the time between successive cases) than COVID-19 virus. The serial interval for COVID-19 virus is estimated to be 5-6 days, while for influenza virus, the serial interval is 3 days. This means that influenza can spread faster than COVID-19.

Further, transmission in the first 3-5 days of illness, or potentially pre-symptomatic transmission - transmission of the virus before the appearance of symptoms - is a major driver of transmission for influenza. In contrast, while we are learning that there are people who can shed COVID-19 virus 24-48 hours prior to symptom onset, at present, this does not appear to be a major driver of transmission.

The reproductive number - the number of secondary infections generated from one infected individual - is understood to be between 2 and 2.5 for COVID-19 virus, higher than for influenza. However, estimates for both COVID-19 and influenza viruses are very context and time-specific, making direct comparisons more difficult.

Children are important drivers of influenza virus transmission in the community. For COVID-19 virus, initial data indicates that children are less affected than adults and that clinical attack rates in the 0-19 age group are low. Further preliminary data from household transmission studies in China suggest that children are infected from adults, rather than vice versa.

While the range of symptoms for the two viruses is similar, the fraction with severe disease appears to be different. For COVID-19, data to date suggest that 80% of infections are mild or asymptomatic, 15% are severe infection, requiring oxygen and 5% are critical infections, requiring ventilation. These fractions of severe and critical infection would be higher than what is observed for influenza infection.

Those most at risk for severe influenza infection are children, pregnant women, elderly, those with underlying chronic medical conditions and those who are immunosuppressed. For COVID-19, our current understanding is that older age and underlying conditions increase the risk for severe infection.

Mortality for COVID-19 appears higher than for influenza, especially seasonal influenza. While the true mortality of COVID-19 will take some time to fully understand, the data we have so far indicate that the crude mortality ratio (the number of reported deaths divided by the reported cases) is between 3-4%, the infection mortality rate (the number of reported deaths divided by the number of infections) will be lower. For seasonal influenza, mortality is usually well below 0.1%. However, mortality is to a large extent determined by access to and quality of health care.




What medical interventions are available for COVID-19 and influenza viruses?

While there are a number of therapeutics currently in clinical trials in China and more than 20 vaccines in development for COVID-19, there are currently no licensed vaccines or therapeutics for COVID-19. In contrast, antivirals and vaccines available for influenza. While the influenza vaccine is not effective against COVID-19 virus, it is highly recommended to get vaccinated each year to prevent influenza infection.







Excerpts from:
www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
Title: Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China
Date: January 24, 2020
Authors:
Prof Chaolin Huang, MD
Yeming Wang, MD
Prof Xingwang Li, MD
Prof Lili Ren, PhD
Prof Jianping Zhao, MD
Yi Hu, MD
Prof Li Zhang, MD
Guohui Fan, MS
Jiuyang Xu, MDc
Xiaoying Gu, PhD
Prof Zhenshun Cheng, MD
Ting Yu, MD
Jiaan Xia, MD
Yuan Wei, MD
Prof Wenjuan Wu, MD
Prof Xuelei Xie, MD
Wen Yin, MD
Hui Li, MD
Min Liu, MD
Yan Xiao, MS
Prof Hong Gao, PhD
Prof Li Guo, PhD
Prof Jungang Xie, MD
Prof Guangfa Wang, MD
Prof Rongmeng Jiang, MD
Prof Zhancheng Gao, MD
Qi Jin, PhD
Prof Jianwei Wang, PhD
Prof Bin Cao, MD

All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died.

[...]

Coronaviruses are enveloped non-segmented positive-sense RNA viruses belonging to the family Coronaviridae and the order Nidovirales and broadly distributed in humans and other mammals.1 Although most human coronavirus infections are mild, the epidemics of the two betacoronaviruses, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) have caused more than 10000 cumulative cases in the past two decades, with mortality rates of 10% for SARS-CoV and 37% for MERS-CoV.

[...]

In December, 2019, a series of pneumonia cases of unknown cause emerged in Wuhan, Hubei, China, with clinical presentations greatly resembling viral pneumonia. Deep sequencing analysis from lower respiratory tract samples indicated a novel coronavirus, which was named 2019 novel coronavirus (2019-nCoV).

[...]

All patients had pneumonia. Common complications included ARDS (12 [29%] of 41 patients), followed by RNAaemia (six [15%] patients), acute cardiac injury (five [12%] patients), and secondary infection (four [10%] patients; table 3). Invasive mechanical ventilation was required in four (10%) patients, with two of them (5%) had refractory hypoxaemia and received extracorporeal membrane oxygenation as salvage therapy. All patients were administered with empirical antibiotic treatment, and 38 (93%) patients received antiviral therapy (oseltamivir). Additionally, nine (22%) patients were given systematic corticosteroids.

[...]

As of Jan 22, 2020, 28 (68%) of 41 patients have been discharged and six (15%) patients have died. Fitness for discharge was based on abatement of fever for at least 10 days, with improvement of chest radiographic evidence and viral clearance in respiratory samples from upper respiratory tract.

[...]

In view of the high amount of cytokines induced by SARS-CoV, MERS-CoV, and 2019-nCoV infections, corticosteroids were used frequently for treatment of patients with severe illness, for possible benefit by reducing inflammatory-induced lung injury. However, current evidence in patients with SARS and MERS suggests that receiving corticosteroids did not have an effect on mortality, but rather delayed viral clearance.

[...]

No antiviral treatment for coronavirus infection has been proven to be effective.







Excerpts from:
twitter.com/DrMattMcCarthy/status/1244616563925417986
Author: Dr Matt McCarthy
Date: Mar 30, 2020

Clinical Update: Most patients require a ventilator due to respiratory failure, which happens when the body is unable to: 1) exhale enough carbon dioxide or 2) breathe in sufficient oxygen. In any ICU, there's usually a mix of these patients. But #COVID19 patients are different:

[...]

With nearly a month of experience, we've seen that COVID patients almost exclusively end up on ventilators due to a lack of oxygen NOT an excess of CO2 (hypercarbic respiratory failure). We've been able to delay, and in many cases avoid, a ventilator with the following approach:

Patients with #coronavirus who are hypoxic (oxygen saturation < 93%) on 6 liters of supplemental oxygen are placed on a non-rebreather. If hypoxia persists, patients are moved to negative pressure room, and high-flow oxygen is used (up to 60 liters).

This buys time, avoids dangers associated with emergent intubation, and in many cases obviates need for a ventilator. Formal protocol is now in development.

Note: protective equipment changes with high-flow oxygen; caregivers wear an impermeable gown, N95, face shield, and hair net. Note: We continue to observe that #coronavirus patients with profound hypoxia experience no symptoms.







Excerpt from:
www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/what-is-the-connection
Title: What Is The Connection Between Influenza and Pneumonia?
Date: February 27, 2020

Influenza (flu) is a highly contagious viral infection that is one of the most severe illnesses of the winter season. Influenza is spread easily from person to person, usually when an infected person coughs or sneezes.

Pneumonia is a serious infection or inflammation of the lungs. The air sacs fill with pus and other liquid, blocking oxygen from reaching the bloodstream. If there is too little oxygen in the blood, the body's cells cannot work properly, which can lead to death.

Influenza is a common cause of pneumonia, especially among younger children, the elderly, pregnant women, or those with certain chronic health conditions or who live in a nursing home. Most cases of flu never lead to pneumonia, but those that do tend to be more severe and deadly. In fact, flu and pneumonia were the eighth leading cause of death in the United States in 2016.

For both influenza and some types of pneumonia there are protective vaccines, although none are 100 percent protective. As flu strains change each year, it is necessary to get a flu vaccination each season to make sure you are protected against the most current strains. Pneumonia vaccinations are usually only necessary once, although a booster vaccination may be recommended for some individuals.







Excerpt from:
www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/what-causes-pneumonia
Title: What Causes Pneumonia?
Date: February 27, 2020

Viruses that infect the upper respiratory tract may also cause pneumonia. The influenza virus is the most common cause of viral pneumonia in adults. Respiratory syncytial virus (RSV) is the most common cause of viral pneumonia in young children. Most viral pneumonias are not serious and last a shorter time than bacterial pneumonia.

Viral pneumonia caused by the influenza virus may be severe and sometimes fatal. The virus invades the lungs and multiplies; however, there are almost no physical signs of lung tissue becoming filled with fluid.







Excerpts from:
www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/symptoms-and-diagnosis
Title: Pneumonia Symptoms and Diagnosis
Date: February 27, 2020

Pneumonia is an infection that inflames your lungs' air sacs (alveoli). The air sacs may fill up with fluid or pus, causing symptoms such as a cough, fever, chills and trouble breathing.

[...]

Pneumonia symptoms can vary from so mild you barely notice them, to so severe that hospitalization is required. How your body responds to pneumonia depends on the type germ causing the infection, your age and your overall health.

The signs and symptoms of pneumonia may include:

- Cough, which may produce greenish, yellow or even bloody mucus
- Fever, sweating and shaking chills
- Shortness of breath
- Rapid, shallow breathing
- Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
- Loss of appetite, low energy, and fatigue
- Nausea and vomiting, especially in small children
- Confusion, especially in older people

[...]

The symptoms of viral pneumonia usually develop over a period of several days. Early symptoms are similar to influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness. Within a day or two, the symptoms typically get worse, with increasing cough, shortness of breath and muscle pain. There may be a high fever and there may be blueness of the lips.

Symptoms may vary in certain populations. Newborns and infants may not show any signs of the infection. Or, they may vomit, have a fever and cough, or appear restless, sick, or tired and without energy. Older adults and people who have serious illnesses or weak immune systems may have fewer and milder symptoms. They may even have a lower than normal temperature. Older adults who have pneumonia sometimes have sudden changes in mental awareness. For individuals that already have a chronic lung disease, those symptoms may worsen.

[...]

See your doctor right away if you have difficulty breathing, develop a bluish color in your lips and fingertips, have chest pain, a high fever, or a cough with mucus that is severe or is getting worse.

It's especially important to get medical attention for pneumonia if you are in a high-risk group, including adults older than age 65, children age two or younger, people with an underlying health condition or weakened immune system. For some of these vulnerable individuals, pneumonia can quickly become a life-threatening condition.







Excerpts from:
www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/treatment-and-recovery
Title: Pneumonia Treatment and Recovery
Date: March 6, 2020

If your pneumonia is caused by bacteria, you will be given an antibiotic.

[...]

Typical antibiotics do not work against viruses. If you have viral pneumonia, your doctor may prescribe an antiviral medication to treat it. Sometimes, though, symptom management and rest are all that is needed.

[...]

Most people can manage their symptoms such as fever and cough at home by following these steps:

- Control your fever with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or naproxen), or acetaminophen. DO NOT give aspirin to children.
- Drink plenty of fluids to help loosen secretions and bring up phlegm.
- Do not take cough medicines without first talking to your doctor. Coughing is one way your body works to get rid of an infection. If your cough is preventing you from getting the rest you need, ask your doctor about steps you can take to get relief.
- Drink warm beverages, take steamy baths and use a humidifier to help open your airways and ease your breathing. Contact your doctor right away if your breathing gets worse instead of better over time.
- Stay away from smoke to let your lungs heal. This includes smoking, secondhand smoke and wood smoke. Talk to your doctor if you are a smoker and are having trouble staying smokefree while you recover. This would be a good time to think about quitting for good.
- Get lots of rest. You may need to stay in bed for a while. Get as much help as you can with meal preparation and household chores until you are feeling stronger. It is important not to overdo daily activities until you are fully recovered.

If your pneumonia is so severe that you are treated in the hospital, you may be given intravenous fluids and antibiotics, as well as oxygen therapy, and possibly other breathing treatments.


Recovering from Pneumonia

It may take time to recover from pneumonia. Some people feel better and are able to return to their normal routines within a week. For other people, it can take a month or more. Most people continue to feel tired for about a month. Adequate rest is important to maintain progress toward full recovery and to avoid relapse. Don't rush your recovery! Talk with your doctor about when you can go back to your normal routine.

While you are recovering, try to limit your contact with family and friends, to help keep your germs from spreading to other people. Cover your mouth and nose when you cough, promptly dispose of tissues in a closed waste container and wash your hands often.

If you have taken antibiotics, your doctor will want to make sure your chest X-ray is normal again after you finish the whole prescription. It may take many weeks for your X-ray to clear up.


Possible Pneumonia Complications

People who may be more likely to have complications from pneumonia include:

- Older adults or very young children.
- People whose immune system does not work well.
- People with other, serious medical problems such as diabetes or cirrhosis of the liver.

Possible complications include:

- Respiratory failure, which requires a breathing machine or ventilator.
- Sepsis, a condition in which there is uncontrolled inflammation in the body, which may lead to widespread organ failure.
- Acute respiratory distress syndrome (ARDS), a severe form of respiratory failure.
- Lung abscesses, which are infrequent, but serious complications of pneumonia. They occur when pockets of pus form inside or around the lung. These may sometimes need to be drained with surgery.







Excerpts from:
www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/preventing-pneumonia
Title: Preventing Pneumonia
Date: March 13, 2020

Tobacco damages your lung's ability to fight off infection, and smokers have been found to be at higher risk of getting pneumonia. Smokers are considered one of the high-risk groups that are encouraged to get the pneumococcal vaccine.

[...]

Since pneumonia often follows respiratory infections, be aware of any symptoms that linger more than a few days.

Good health habits - a healthy diet, rest, regular exercise, etc. - help you from getting sick from viruses and respiratory illnesses. They also help promote fast recovery when you do get a cold, the flu or other respiratory illness.







Excerpt from:
www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30114-5/fulltext
Title: Use of antiviral drugs to reduce COVID-19 transmission
Authors: Oriol Mitja, Bonaventura Clotet
Date: March 19, 2020

The antimalarial drug, hydroxychloroquine, is licensed for the chemoprophylaxis and treatment of malaria and as a disease-modifying antirheumatic drug. It has a history of being safe and well tolerated at typical doses. Notably, the drug shows antiviral activity in vitro against coronaviruses, and specifically, SARS-CoV-2. Pharmacological modelling based on observed drug concentrations and in vitro drug testing suggest that prophylaxis with hydroxychloroquine at approved doses could prevent SARS-CoV-2 infection and ameliorate viral shedding. Clinical trials of hydroxychloroquine treatment for COVID-19 pneumonia are underway in China (NCT04261517 and NCT04307693)







Excerpt from:
www.cdc.gov/flu/symptoms/symptoms.htm
Title: Flu Symptoms & Complications
Date: September 18, 2019

Flu Complications

Most people who get flu will recover in a few days to less than two weeks, but some people will develop complications (such as pneumonia) as a result of flu, some of which can be life-threatening and result in death.

Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a serious flu complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart (myocarditis), brain (encephalitis) or muscle (myositis, rhabdomyolysis) tissues, and multi-organ failure (for example, respiratory and kidney failure). Flu virus infection of the respiratory tract can trigger an extreme inflammatory response in the body and can lead to sepsis, the body's life-threatening response to infection. Flu also can make chronic medical problems worse. For example, people with asthma may experience asthma attacks while they have flu, and people with chronic heart disease may experience a worsening of this condition triggered by flu.







Excerpts from:
newsnetwork.mayoclinic.org/discussion/influenza-and-sepsis-mayo-expert-describes-warning-signs-of-severe-sepsis-septic-shock
Author: Sharon Theimer
Date: January 13, 2015

Sepsis can be a dangerous complication of almost any type of infection, including influenza, pneumonia and food poisoning; urinary tract infections; bloodstream infections from wounds; and abdominal infections. Steve Peters, M.D., a pulmonary and critical care physician at Mayo Clinic and senior author of a recent sepsis overview in the medical journal Mayo Clinic Proceedings, explains sepsis symptoms and risk factors, the difference between severe sepsis and septic shock, and how sepsis is typically treated:

What is sepsis?

Sepsis occurs when chemicals released into the bloodstream to fight an infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail.

What are symptoms to watch for?

A high fever; inability to keep fluids down; rapid heartbeat; rapid, shallow breathing; lethargy and confusion are among the signs. If sepsis is suspected, seek emergency care, Dr. Peters advises. Rapid intervention is critical.

[...]

How is sepsis treated?

The first step is diagnosis: Cultures are taken from the blood and any other relevant parts of the body. Intravenous fluids are given, and antibiotics are usually started right away.

"Probably the single most important thing is to try to maintain fluids," Dr. Peters says. "The damage of sepsis probably begins with loss of fluids."

If sepsis is severe, with rapid heart rate, rapid breathing and shortness of breath, and the initial fluid given doesn't prompt rapid improvement, patients are usually hospitalized.

What are the differences among sepsis, severe sepsis and septic shock?

Sepsis refers to signs of inflammation in the presence of a presumed infection, Dr. Peters says.

"Severe sepsis means you've got that and signs of organ damage: lung injury, impaired kidney function, impaired liver function," Dr. Peters explains. "Septic shock means you have all of those findings of severe sepsis, but now you've been given fluids, and there's still poor blood pressure, poor urine output, breathing troubles, and there are still ongoing signs of sepsis."

Septic shock can be fatal. Among hospitalized patients, septic shock is associated with a 20 to 30 percent risk of death, Dr. Peters says.

[...]

Who's at risk?

Anyone can develop sepsis. People on chemotherapy or other immune-suppressing drugs are at higher risk, as are the elderly and people with open wounds that could lead to infection. Often, immune-suppressed patients are given antibiotics preventively.

Is there anything you can do to prevent sepsis if you catch the flu or another illness?

"Taking your temperature is important, because it gives a good assessment of how severe this might be," Dr. Peters says. "Probably the single most important thing is to try to continue taking in fluids. Watch for signs and symptoms, and seek urgent medical care if you suspect sepsis."







Excerpts from:
www.healthline.com/health/can-you-die-from-the-flu
Title: Can You Die from the Flu?
Author: Ana Gotter
Medically reviewed by Daniel Murrell, MD
Date: January 3, 2019

How do people die from the flu?

People often mistake the flu for a bad cold, since flu symptoms mimic a cold. When you catch the flu, you might experience coughing, sneezing, runny nose, hoarse voice, and a sore throat.

But flu can progress into conditions like pneumonia, or worsen other chronic issues like chronic obstructive pulmonary disease (COPD) and congestive heart failure, which can quickly become life-threatening.

Flu can directly lead to death when the virus triggers severe inflammation in the lungs. When this happens, it can cause rapid respiratory failure because your lungs can't transport enough oxygen into the rest of your body.

The flu can also cause your brain, heart, or muscles to become inflamed. This can lead to sepsis, an emergency condition that can be fatal if not immediately treated.

If you develop a secondary infection while you have the flu, that can also cause your organs to fail. The bacteria from that infection can get into your bloodstream and cause sepsis, as well.

In adults, symptoms of life-threatening flu complications include:

- feeling short of breath
- trouble breathing
- disorientation
- feeling suddenly dizzy
- abdominal pain that is severe
- pain in the chest
- severe or ongoing vomiting

[...]

People with compromised immune systems are at a higher risk of developing complications - and possibly dying - from the flu.

When your immune system is weakened, you're more likely to experience viruses and infections in a more severe form. And your body will have a harder time not only fighting those off, but also fighting any subsequent infections that could develop.

For example, if you already have asthma, diabetes, an autoimmune disorder, lung disease, or cancer, getting the flu could cause those conditions to get worse. If you have a kidney condition, getting dehydrated from the flu could worsen your kidney function.

Who is most at risk for dying from the flu?

Children under age 5 (especially children under 2) and adults 65 and over are at the highest risk of developing severe complications from the flu, being hospitalized, and dying. Other people at high risk of dying from flu include:

- children 18 and under who are taking aspirin- or salicylate-based medications
- women who are pregnant or are less than two weeks postpartum
- anyone who experiences chronic illness
- people who have compromised immune systems
- people living in long-term care, assisted living facilities, or nursing homes
- people who have a BMI of 40 or over
- organ donor recipients who take anti-rejection drugs
- people living in close quarters (like members of the military)
- people with HIV or AIDS

Adults 65 and up, including the elderly, are more likely to have chronic illness or compromised immune systems and tend to be more susceptible to infections like pneumonia. On the other hand, children tend to be more likely to have an immune over-response to flu strains they haven't been exposed to before.







Excerpt from:
www.scientificamerican.com/article/how-does-the-flu-actually-kill-people
Title: How Does the Flu Actually Kill People?
Author: Ferris Jabr
Date: December 18, 2017

What exactly is a "flu-related death"? How does the flu kill? The short and morbid answer is that in most cases the body kills itself by trying to heal itself. "Dying from the flu is not like dying from a bullet or a black widow spider bite," says Amesh Adalja, an infectious disease physician at the Johns Hopkins University Center for Health Security. "The presence of the virus itself isn't going to be what kills you. An infectious disease always has a complex interaction with its host."

After entering someone's body - usually via the eyes, nose or mouth - the influenza virus begins hijacking human cells in the nose and throat to make copies of itself. The overwhelming viral hoard triggers a strong response from the immune system, which sends battalions of white blood cells, antibodies and inflammatory molecules to eliminate the threat. T cells attack and destroy tissue harboring the virus, particularly in the respiratory tract and lungs where the virus tends to take hold. In most healthy adults this process works, and they recover within days or weeks. But sometimes the immune system's reaction is too strong, destroying so much tissue in the lungs that they can no longer deliver enough oxygen to the blood, resulting in hypoxia and death.

In other cases it is not the flu virus itself that triggers an overwhelming and potentially fatal immune response but rather a secondary infection that takes advantage of a taxed immune system. Typically, bacteria - often a species of Streptococcus or Staphylococcus - infect the lungs. A bacterial infection in the respiratory tract can potentially spread to other parts of the body and the blood, even leading to septic shock: a life-threatening, body-wide, aggressive inflammatory response that damages multiple organs. Based on autopsy studies, Kathleen Sullivan, chief of the Division of Allergy and Immunology at The Children's Hospital of Philadelphia, estimates about one third of people who die from flu-related causes expire because the virus overwhelms the immune system; another third die from the immune response to secondary bacterial infections, usually in the lungs; and the remaining third perish due to the failure of one or more other organs.

Apart from a bacterial pneumonia, the secondary complications of the flu are numerous and range from the relatively mild, such as sinus and ear infections, to the much more severe, such as inflammation of the heart (myocarditis), brain (encephalitis) or muscles (myositis and rhabdomyolysis). They can also include Reye's syndrome, a mysterious brain illness that usually begins after a viral infection, and Guillain-Barr syndrome, another virus-triggered ailment in which the immune system attacks the peripheral nervous system. Sometimes Guillain-Barr leads to a period of partial or near-total paralysis, which in turn requires mechanical ventilation to keep a sufferer breathing. These complications are less common, but can be fatal.

The number of people who die from an immune response to the initial viral infection versus a secondary bacterial infection depends, in part, on the viral strain and the cleanliness of the spaces in which the sick are housed. Some studies suggest that during the infamous 1918 global flu pandemic, most people died from subsequent bacterial infections. But more virulent strains such as those that cause avian flu are more likely to overwhelm the immune system on their own. "The hypothesis is that virulent strains trigger a stronger inflammatory response," Adalja says. "It also depends on the age group getting attacked. During the H1N1 2009 pandemic, the age group mostly affected was young adults, and we saw a lot of primary viral pneumonia."

In a typical season most flu-related deaths occur among children and the elderly, both of whom are uniquely vulnerable. The immune system is an adaptive network of organs that learns how best to recognize and respond to threats over time. Because the immune systems of children are relatively naive, they may not respond optimally. In contrast the immune systems of the elderly are often weakened by a combination of age and underlying illness. Both the very young and very old may also be less able to tolerate and recover from the immune system's self-attack. Apart from children between six and 59 months and individuals older than 65 years, those at the greatest risk of developing potentially fatal complications are pregnant women, health care workers and people with certain chronic medical conditions, such as HIV/AIDS, asthma, and heart or lung diseases, according to the World Health Organization.







Excerpts from:
www.nhlbi.nih.gov/health-topics/respiratory-failure
Title: Respiratory Failure

Respiratory (RES-pih-rah-tor-e) failure is a condition in which not enough oxygen passes from your lungs into your blood. Your body's organs, such as your heart and brain, need oxygen-rich blood to work well.

Respiratory failure also can occur if your lungs can't properly remove carbon dioxide (a waste gas) from your blood. Too much carbon dioxide in your blood can harm your body's organs.

Both of these problems - a low oxygen level and a high carbon dioxide level in the blood - can occur at the same time.

Diseases and conditions that affect your breathing can cause respiratory failure. Examples include COPD (chronic obstructive pulmonary disease) and spinal cord injuries. COPD prevents enough air from flowing in and out of the airways. Spinal cord injuries can damage the nerves that control breathing.

[...]

To understand respiratory failure, it helps to understand how the lungs work. When you breathe, air passes through your nose and mouth into your windpipe. The air then travels to your lungs' air sacs. These sacs are called alveoli (al-VEE-uhl-eye).

Small blood vessels called capillaries run through the walls of the air sacs. When air reaches the air sacs, the oxygen in the air passes through the air sac walls into the blood in the capillaries. At the same time, carbon dioxide moves from the capillaries into the air sacs. This process is called gas exchange.

In respiratory failure, gas exchange is impaired.

Respiratory failure can be acute (short term) or chronic (ongoing). Acute respiratory failure can develop quickly and may require emergency treatment. Chronic respiratory failure develops more slowly and lasts longer.

Signs and symptoms of respiratory failure may include shortness of breath, rapid breathing, and air hunger (feeling like you can't breathe in enough air). In severe cases, signs and symptoms may include a bluish color on your skin, lips, and fingernails; confusion; and sleepiness.

One of the main goals of treating respiratory failure is to get oxygen to your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat the underlying cause of the condition.

Acute respiratory failure usually is treated in an intensive care unit. Chronic respiratory failure can be treated at home or at a long-term care center.

[...]

People who have severe lung diseases may need long-term or ongoing breathing support, such as oxygen therapy or the help of a ventilator (VEN-til-a-tor). A ventilator is a machine that supports breathing. It blows air - or air with increased amounts of oxygen - into your airways and then your lungs.

[...]

When respiratory failure causes a low level of oxygen in the blood, it's called hypoxemic (HI-pok-SE-mik) respiratory failure.
When respiratory failure causes a high level of carbon dioxide in the blood, it's called hypercapnic (HI-per-KAP-nik) respiratory failure.

[...]

If you have respiratory failure, you may receive oxygen therapy. Extra oxygen is given through a nasal cannula (two small plastic tubes, or prongs, that are placed in both nostrils) or through a mask that fits over your nose and mouth.

Oxygen also can be given through a tracheostomy (TRA-ke-OS-to-me). This is a surgically made hole that goes through the front of your neck and into your windpipe. A breathing tube, also called a tracheostomy or trach tube, is placed in the hole to help you breathe.

If the oxygen level in your blood doesn't increase, or if you're still having trouble breathing, your doctor may recommend a ventilator. A ventilator is a machine that supports breathing. It blows air - or air with increased amounts of oxygen - into your airways and then your lungs.

Your doctor will adjust the ventilator as needed. This will help your lungs get the right amount of oxygen. It also can prevent the machine's pressure from injuring your lungs. You'll use the ventilator until you can breathe on your own.

[...]

Noninvasive positive pressure ventilation (NPPV) and a rocking bed are two methods that can help you breathe better while you sleep. These methods are very useful for people who have chronic respiratory failure.

NPPV is a treatment that uses mild air pressure to keep your airways open while you sleep. You wear a mask or other device that fits over your nose or your nose and mouth. A tube connects the mask to a machine, which blows air into the tube.

CPAP (continuous positive airway pressure) is one type of NPPV. For more information, go to the Health Topics CPAP article. Although the article focuses on CPAP treatment for sleep apnea, it explains how CPAP works.

A rocking bed consists of a mattress on a motorized platform. The mattress gently rocks back and forth. When your head rocks down, the organs in your abdomen and your diaphragm (the main muscle used for breathing) slide up, helping you exhale. When your head rocks up, the organs in your abdomen and your diaphragm slide down, helping you inhale.

[...]

You may be given fluids to improve blood flow throughout your body and to provide nutrition. Your doctor will make sure you get the right amount of fluids.

Too much fluid can fill the lungs and make it hard for you to get the oxygen you need. Not enough fluid can limit the flow of oxygen-rich blood to the body's organs.

Fluids usually are given through an intravenous (IV) line inserted in one of your blood vessels.







Excerpt from:
www.sciencedaily.com/releases/2014/02/140227142250.htm
Title: Deadly immune 'storm' caused by emergent flu infections
Source: The Scripps Research Institute
Date: February 27, 2014

Summary:

Scientists have mapped key elements of a severe immune overreaction -- a "cytokine storm" -- that can both sicken and kill patients who are infected with certain strains of flu virus. A cytokine storm is an overproduction of immune cells and their activating compounds (cytokines), which, in a flu infection, is often associated with a surge of activated immune cells into the lungs. The resulting lung inflammation and fluid buildup can lead to respiratory distress and can be contaminated by a secondary bacterial pneumonia -- often enhancing the mortality in patients.







Excerpt from:
www.bmj.com/content/369/bmj.m1395
Title: Covid-19: Why Germany's case fatality rate seems so low
Author: Ned Stafford, freelance journalist
Date: 07 April 2020
Provenance and peer review: Commissioned; not externally peer reviewed.

As the covid-19 pandemic continues to grow in severity, one of the most closely watched statistics has been Germany's number of deaths from the virus, which has been remarkably low in comparison with other nations, especially neighbouring European countries.

As of 2 April official statistics showed that 872 deaths from covid-19 had been recorded in Germany from 73522 confirmed cases, translating to a fatality rate of 1.2%. This compares with fatality rates of 11.9% in Italy, 9% in Spain, 8.6% in the Netherlands, 8% in the UK, and 7.1% in France.

Christian Drosten, director of the Institute of Virology at the Charite hospital in Berlin, believes that Germany's relatively low covid-19 fatality rate can be attributed partly to the nation's early and high level of testing among a wide sample of the German population. While other countries were conducting a limited number of tests of older patients with severe cases of the virus, Germany was conducting many more tests that included milder cases in younger people.

The more tests are performed, the more likely it is that new cases will be found, and the higher total case numbers are relative to the proportion of cases that lead to death. Thus, the fatality rate decreases as this ratio widens.







Excerpt from:
www.newscientist.com/article/2239497-why-we-still-dont-know-what-the-death-rate-is-for-covid-19
Title: Why we still don't know what the death rate is for covid-19
Author: Michael Le Page
Date: 3 April 2020

What are your chances of dying if you get infected by the new coronavirus? Despite data pouring in from many countries, there is still a wide range of estimates, from as low as 1 in 1000 to as high as 1 in 30.

What is clear is that there is no one answer: the risk depends on your age, sex, health and the care you receive if you become severely ill. In other words, death rates will vary from place to place and over the course of the pandemic.

In the UK, as of 2 April, 2921 people had died out of 33,718 confirmed cases - a crude case fatality rate of around 9 per cent. For Italy, the figure is nearly 12 per cent and for Germany just 1 per cent.

These figures don't tell us what we really want to know, though: how many of those infected will die as a result, which is known as the infection fatality rate.

Crude case fatality rates are so-called because they don't take into account the fact that some of the people counted in the infected numbers have not recovered yet and may still go on to die. Early in March, for instance, South Korea had a crude case fatality rate of just 0.6 per cent. That has risen to 1.7 per cent. Among resolved cases - those who have died or recovered - the case fatality rate is 2.9 per cent.

The differences between countries are also partly to do with how many older people have been infected, says Melinda Mills at the Leverhulme Centre for Demographic Science in the UK. In South Korea and Germany, the first people to be infected were mostly younger.

Based on what is happening in Italy, Mills and her colleagues calculate that if 10 per cent of people become infected, there would be 302,530 deaths in Italy, with its ageing population of 61 million, but 142,058 deaths in Nigeria, with its much younger population of 191 million.

The big question is how many infected people with mild or no symptoms are being missed. If lots are, the infection fatality rate will be much lower than the case fatality rate. We know the UK is testing only severely ill people and missing lots of mild cases, but South Korea and Germany have been testing more widely.

Neil Ferguson's team at Imperial College London has estimated the number of missed cases based on how many people who were evacuated from Wuhan tested positive. They concluded that the infection fatality rate in China is 0.66 per cent.

Julien Riou at the University of Bern in Switzerland instead assumes all covid-19 cases among people over 80 are being detected. His team estimates that the infection fatality rate in Italy is 3.3 per cent, rising from 1 per cent among people aged between 50 and 59 to nearly 90 per cent in those aged 80 or above. For China and Spain, the overall rate is 3 per cent. If half of cases in those over 80 are being missed, it would halve these figures, says Riou.

At the other end of the spectrum, Jason Oke at the University of Oxford thinks not all of the deaths attributed to the coronavirus are caused by it. He points out that while there is an excess of deaths in Italy according to EuroMOMO, a public health monitoring organisation, it isn't as large as that during the last bad flu season in 2016. His team thinks the infection fatality rate could be as low as 0.1 per cent.

But on 1 April, the EuroMOMO website had a highlighted warning against drawing such conclusions based on its data. While that warning has since been removed, it still states that the "number of deaths in recent weeks should be interpreted with caution".

What's more, it has also been reported that one badly hit town in Italy called Nembro has reported 158 deaths so far this year compared with 35 on average each year for the past five years. Only 31 of the 158 deaths were recorded as due to covid-19.

For now we still can't say for sure what the infection fatality rates are. This will start to become clearer once antibody testing reveals who has been infected in the past, and thus the number of missed cases.







Excerpts from:
www.livescience.com/new-coronavirus-compare-with-flu.html
Title: How does the new coronavirus compare with the flu?
Author: Rachael Rettner
Date: March 25, 2020

The new coronavirus causing COVID-19 has led to more than 454,000 illnesses and more than 20,550 deaths worldwide. For comparison, in the U.S. alone, the flu (also called influenza) has caused an estimated 38 million illnesses, 390,000 hospitalizations and 23,000 deaths this season, according to the Centers for Disease Control and Prevention (CDC).

That said, scientists have studied seasonal flu for decades. So, despite the danger of it, we know a lot about flu viruses and what to expect each season. In contrast, very little is known about the new coronavirus and the disease it causes, dubbed COVID-19, because it's so new. This means COVID-19 is something of a wild card in terms of how far it will spread and how many deaths it will cause.

"Despite the morbidity and mortality with influenza, there's a certainty ... of seasonal flu," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a White House press conference on Jan. 31. "I can tell you all, guaranteed, that as we get into March and April, the flu cases are going to go down. You could predict pretty accurately what the range of the mortality is and the hospitalizations [will be]," Fauci said. "The issue now with [COVID-19] is that there's a lot of unknowns." (During the week ending March 14, 15.3% of tests for a respiratory illness turned out positive for flu, compared with 21.1% the week prior.)

[...]

Most people who get the flu will recover in less than two weeks. But in some people, the flu causes complications, including pneumonia. So far this flu season, about 1% of people in the United States have developed symptoms severe enough to be hospitalized. And the overall hospitalization rate in the U.S. this season is 61 hospitalizations per 100,000 people.

In general, studies of hospitalized patients have found that about 83% to 98% of patients develop a fever, 76% to 82% develop a dry cough and 11% to 44% develop fatigue or muscle aches, according to a review study on COVID-19 published Feb. 28 in the journal JAMA. Other symptoms, including headache, sore throat, abdominal pain, and diarrhea, have been reported, but are less common. A less common symptom, loss of smell, has also been reported in some COVID-19 patients, Live Science reported.

Another recent study, considered the largest on COVID-19 cases to date, researchers from the Chinese Center for Disease Control and Protection, analyzed 44,672 confirmed cases in China between Dec. 31, 2019 and Feb. 11, 2020. Of those cases, 80.9% (or 36,160 cases) were considered mild, 13.8% (6,168 cases) severe and 4.7% (2,087) critical. "Critical cases were those that exhibited respiratory failure, septic shock, and/or multiple organ dysfunction/failure," the researchers wrote in the paper published in China CDC Weekly [ http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51 ].

A recent study of COVID-19 cases in the United States found that, among 4,226 reported cases , at least 508 people, or 12% were hospitalized. However, the study, published March 18 in the CDC journal Morbidity and Mortality Weekly Report (MMWR) is preliminary, and the researchers note that data on hospitalizations were missing for a substantial number of patients.

It's important to note that, because respiratory viruses cause similar symptoms, it can be difficult to distinguish different respiratory viruses based on symptoms alone, according to WHO.







Excerpts from:
weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51
Title: Vital Surveillances: The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) - China, 2020
Source: The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team
Date: February 17 2020
Corresponding author: Yanping Zhang, zhangyp@chinacdc.cn
Author Group & Contributions: The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team includes Zijian Feng, Qun Li, Yanping Zhang, Zunyou Wu, Xiaoping Dong, Huilai Ma, Dapeng Yin, Ke Lyu, Dayan Wang, Lei Zhou, Ruiqi Ren, Chao Li, Yali Wang, Dan Ni, Jing Zhao, Bin Li, Rui Wang, Yan Niu, Xiaohua Wang, Lijie Zhang, Jingfang Sun, Boxi Liu, Zhiqiang Deng, Zhitao Ma, Yang Yang, Hui Liu, Ge Shao, Huan Li, Yuan Liu, Hangjie Zhang, Shuquan Qu, Wei Lou, Dou Shan, Yuehua Hu, Lei Hou, Zhenping Zhao, Jiangmei Liu, Hongyuan Wang, Yuanjie Pang, Yuting Han, Qiuyue Ma, Yujia Ma, Shi Chen, Wei Li, Routong Yang, Zhewu Li, Yingnan Guo, Xinran Liu, Bahabaike Jiangtulu, Zhaoxue Yin, Juan Xu, Shuo Wang, Lin Xiao, Tao Xu, Limin Wang, Xiao Qi, Guoqing Shi, Wenxiao Tu, Xiaomin Shi, Xuemei Su, Zhongjie Li, Huiming Luo, Jiaqi Ma, Jennifer M. McGoogan. All Team members jointly conceptualized the study, analyzed and interpreted the data, wrote and revised the manuscript, and decided to submit for publication.

Results: A total of 72,314 patient records - 44,672 (61.8%) confirmed cases, 16,186 (22.4%) suspected cases, 10,567 (14.6%) clinically diagnosed cases (Hubei Province only), and 889 asymptomatic cases (1.2%) - contributed data for the analysis. Among confirmed cases, most were aged 30-79 years (86.6%), diagnosed in Hubei (74.7%), and considered mild (80.9%). A total of 1,023 deaths occurred among confirmed cases for an overall case fatality rate of 2.3%.

[...]

The >= 80 age group had the highest case fatality rate of all age groups at 14.8%. Case fatality rate for males was 2.8% and for females was 1.7%.

While patients who reported no comorbid conditions had a case fatality rate of 0.9%, patients with comorbid conditions had much higher rates - 10.5% for those with cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer. Case fatality rate was also very high for cases categorized as critical at 49.0%.

[...]

The virus is distinct from both SARS-CoV and MERS-CoV, yet closely related (5,7). Early cases suggested that COVID-19 (i.e. the new name for disease caused by the novel coronavirus) may be less severe than SARS and MERS. However, illness onset among rapidly increasing numbers of people and mounting evidence of human-to-human transmission suggests that 2019-nCoV is more contagious than both SARS-CoV and MERS-CoV.

[...]

The severity of symptoms variable was categorized as mild, severe, or critical. Mild included non-pneumonia and mild pneumonia cases. Severe was characterized by dyspnea, respiratory frequency >= 30/minute, blood oxygen saturation <= 93%, PaO2/FiO2 ratio <300, and/or lung infiltrates >50% within 24-48 hours. Critical cases were those that exhibited respiratory failure, septic shock, and/or multiple organ dysfunction/failure.







Excerpt from:
www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
Title: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand
Source: Imperial College COVID-19 Response Team
Corresponding author: Neil M Ferguson
Date: 16 March 2020
Authors: Neil M Ferguson, Daniel Laydon, Gemma Nedjati-Gilani, Natsuko Imai, Kylie Ainslie, Marc Baguelin, Sangeeta Bhatia, Adhiratha Boonyasiri, Zulma Cucunuba, Gina Cuomo-Dannenburg, Amy Dighe, Ilaria Dorigatti, Han Fu, Katy Gaythorpe, Will Green, Arran Hamlet, Wes Hinsley, Lucy C Okell, Sabine van Elsland, Hayley Thompson, Robert Verity, Erik Volz, Haowei Wang, Yuanrong Wang, Patrick GT Walker, Caroline Walters, Peter Winskill, Charles Whittaker, Christl A Donnelly, Steven Riley, Azra C Ghani.

The age-stratified proportion of infections that require hospitalisation and the infection fatality ratio (IFR) were obtained from an analysis of a subset of cases from China. These estimates were corrected for non-uniform attack rates by age and when applied to the GB population result in an IFR of 0.9% with 4.4% of infections hospitalised.

We assume that 30% of those that are hospitalised will require critical care (invasive mechanical ventilation or ECMO) based on early reports from COVID-19 cases in the UK, China and Italy (Professor Nicholas Hart, personal communication). Based on expert clinical opinion, we assume that 50% of those in critical care will die and an age-dependent proportion of those that do not require critical care die (calculated to match the overall IFR).







Excerpts from:
www2.hse.ie/conditions/coronavirus/coronavirus-treatment.html
Title: Treatment - Coronavirus (COVID-19)
Date: 12 April 2020

Caring for yourself at home

About 80% of people can recover from coronavirus at home and without needing to go to hospital.

If you are generally fit and healthy with only mild symptoms of coronavirus, your GP will tell you to self-isolate.

The most important thing you can do is to protect others from catching it. It is especially important to protect people in at-risk groups from catching coronavirus.

You should:

- self-isolate
- get lots of rest and sleep.
- drink enough water to avoid dehydration. Your pee should be light yellow or clear
- eat healthily
- do not smoke
- keep warm
- monitor and treat your symptoms

[...]

Paracetamol or ibuprofen may help to lower your temperature and treat aches and pains. Paracetamol is usually recommended as the first-line treatment for most people.

[...]

Vaccine

There is currently no vaccine to treat or protect against coronavirus.

The flu vaccine does not protect against coronavirus.

[...]

Ibuprofen and other anti-inflammatory medication

It is okay to take anti-inflammatories (NSAID) if you have coronavirus. There is no evidence that they are unsafe.

Only take one anti-inflammatory medication at a time. It is okay to take paracetamol and an anti-inflammatory like ibuprofen at the same time.

Anti-inflammatory medicines include:

- ibuprofen - brand names: Nurofen, Actiprofen, Advil, Brufen, Brupro, Buplex, Easofen, and Fenopine. Ibuprofen gel can be called Nurofen, Melfen, Phorpain, Ibugel and Ibuleve
- naproxen - brand name: Naprosyn
- diclofenac - brand names: Voltarol, Diclo, Diclac, Cataflam, Difene and Flector

[...]

Hospital treatment

Around 14% of people who catch coronavirus will have a more severe illness. If your symptoms get worse and you feel very unwell you may need to go to hospital.

Treatment at hospital for coronavirus may include:

- medication to reduce a fever
- oxygen therapy

People who have a hard time breathing on their own due to coronavirus may need a respirator. Life support can be used in extreme cases.






Excerpt from:
www.mayoclinic.org/diseases-conditions/flu/diagnosis-treatment/drc-20351725
Title: Influenza (flu) / Diagnosis & treatment
Date: Oct. 04, 2019

Treatment

Usually, you'll need nothing more than bed rest and plenty of fluids to treat the flu. But if you have severe infection or are at higher risk for complications, your doctor may prescribe an antiviral medication, such as oseltamivir (Tamiflu), zanamivir (Relenza), peramivir (Rapivab) or baloxavir (Xofluza). These drugs may shorten your illness by a day or so and help prevent serious complications.

Oseltamivir is an oral medication. Zanamivir is inhaled through a device similar to an asthma inhaler and shouldn't be used by anyone with certain chronic respiratory problems, such as asthma and lung disease.

Antiviral medication side effects may include nausea and vomiting. These side effects may be lessened if the drug is taken with food.

Most circulating strains of influenza have become resistant to amantadine and rimantadine (Flumadine), which are older antiviral drugs that are no longer recommended.







Excerpt from:
www.nhs.uk/medicines/ibuprofen-for-adults
Title: Ibuprofen for adults (including Nurofen)
Date: 7 December 2018

NHS coronavirus advice

There is currently no strong evidence that non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen can make coronavirus (COVID-19) worse.

But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you.

If you have no coronavirus symptoms and regularly take ibuprofen for pain relief, carry on taking it as usual. If you develop coronavirus symptoms, ask your doctor about changing to paracetamol instead.

Updated: 20 March 2020







Excerpts from:
www.healthline.com/health/rebreather-mask
Title: How Non-Rebreather Masks Work
Author: Aimee Eyvazzadeh, MD, MPH
Medically reviewed by Deborah Weatherspoon, PhD, RN, CRNA
Date: March 30, 2020

What is a non-rebreather mask?

A non-rebreather mask is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that's filled with a high concentration of oxygen. The reservoir bag is connected to an oxygen tank.

The mask covers both your nose and mouth. One-way valves prevent exhaled air from reentering the oxygen reservoir.

A non-rebreather mask is used in emergency situations to prevent hypoxemia, also known as low blood oxygen. Conditions that disrupt your lungs' ability to uptake oxygen or your heart's ability to pump blood can cause low blood oxygen levels.

If your blood oxygen levels drop too low, you can develop a condition called hypoxia, where your essential tissues become oxygen-deprived.


How does a non-rebreather mask work?

A non-rebreather face mask fits over your mouth and nose and attaches with an elastic band around your head. The mask is connected to a plastic reservoir bag filled with a high concentration of oxygen. The mask has a one-way valve system that prevents exhaled oxygen from mixing with the oxygen in the reservoir bag.

When you inhale, you breathe in oxygen from the reservoir bag. Exhaled air escapes through vents in the side of the mask and goes back into the atmosphere.

Non-rebreather masks allow you to receive a higher concentration of oxygen than with standard masks. They're generally only used for short-term increases in oxygenation.

Non-rebreather masks aren't commonly used because they come with several risks. Disruptions in airflow can lead to suffocation. You can potentially choke if you vomit while wearing the mask if you're sedated or unconscious. A healthcare provider usually remains in attendance during use of this type mask.

[...]

Non-rebreather vs. simple mask and rebreather

A simple face mask is usually used to deliver a low to moderate amount of oxygen. A simple mask contains holes on the sides to let exhaled air through and to prevent suffocation in case of a blockage.

It can deliver around 40 percent to 60 percent oxygen at 6 to 10 L/min. It's used for people who can breathe on their own but may have low blood oxygen levels.

A simple face mask doesn't deliver as high of an oxygen concentration as a non-rebreather mask but is safer in the case of a blockage. A medical professional will make a decision of which type of oxygen delivery system is needed based on the specific condition being treated and blood oxygen levels.

A rebreather mask is a misnomer and doesn't exist in the context of oxygen therapy. The term "rebreather mask" usually refers to a simple mask.


Can I use a non-rebreathing mask at home?

Non-rebreathing masks are not available for home use. A non-rebreathing mask is meant for short-term use in situations such as transporting people to a hospital. They're rarely used outside of an emergency department and should only be used under medical supervision. If the oxygen flow is disrupted, it can lead to suffocation.

A doctor may recommend home oxygen therapy to people with long-term conditions like chronic obtrusive pulmonary disease, severe asthma, or cystic fibrosis.

Home oxygen therapy can be delivered through oxygen tanks or an oxygen concentrator. It's often administered through nasal cannula or tubes that insert into your nostrils. It may also be administered through a face mask.







Excerpt from:
www.medrxiv.org/content/10.1101/2020.04.08.20058578v1
Title: The Role of Vitamin D in Suppressing Cytokine Storm in COVID-19 Patients and Associated Mortality
Authors: Ali Daneshkhah, Adam Eshein, Hariharan Subramanian, Hemant Kumar Roy, Vadim Backman
Date: April 10, 2020
This article is a preprint and has not been certified by peer review. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

Interpretation: The substantially higher age-specific CFR and the age-specific ratio of confirmed cases in Italy and Spain (countries with low mean 25OHD level) suggest a potential link between severe Vit D deficiency and severe COVID-19, which can lead to a higher CFR. No direct link between the performance of health care systems, the age distribution of the nation, or Vitamin A deficiency and the CFR of COVID-19 were observed. Our analysis of the published data on the status of Vit D and CRP levels (in the US) and laboratory data (CRP levels) reported from 792 patients in China suggests that a proper supplementation of Vit D across populations may reduce the number of severe COVID-19 cases by up to 15 percentage points by lowering the risk factors related to cytokine storm.







Excerpts from:
www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d
Title: Vitamin D
Date: 3 March 2017

From about late March/early April to the end of September, most people should be able to get all the vitamin D they need from sunlight.

The body creates vitamin D from direct sunlight on the skin when outdoors.

But between October and early March we don't get enough vitamin D from sunlight. Read more about vitamin D and sunlight.

Vitamin D is also found in a small number of foods.

Sources include:

- oily fish - such as salmon, sardines, herring and mackerel
- red meat
- liver
- egg yolks
- fortified foods - such as most fat spreads and some breakfast cereals

[...]

During the autumn and winter, you need to get vitamin D from your diet because the sun isn't strong enough for the body to make vitamin D.

But since it's difficult for people to get enough vitamin D from food alone, everyone (including pregnant and breastfeeding women) should consider taking a daily supplement containing 10 micrograms of vitamin D during the autumn and winter.







Excerpt from:
www.bda.uk.com/resource/covid-19-corona-virus-advice-for-the-general-public.html
Title: COVID-19 / Coronavirus - Advice for the General Public
Date: April 7 2020

Should I take a vitamin D supplement?

Vitamin D works with calcium and phosphorus for healthy bones, muscles and teeth. It is also important in protecting muscle strength and preventing rickets, osteomalacia and falls.

In normal circumstances, sunshine, not food, is where most of your vitamin D comes from. So even a healthy, well-balanced diet, that provides all the other vitamins and nutrients you need, is unlikely to provide enough vitamin D if you aren't able to get enough sun. During autumn and winter months when we spend more time indoors and the sun is weaker, adults and children over the age of one are advised to take a daily supplement containing 10 micrograms of Vitamin D.

You can also eat plenty of vitamin D rich foods, including:

- Oily fish such as salmon, sardines, pilchards, trout, herring, kippers and eel contain reasonable amounts of vitamin D.
- Cod liver oil contains a lot of vitamin D, but don't take this if you are pregnant.
- Egg yolk, meat, offal and milk contain small amounts, but this varies during the seasons.
- Margarine, some breakfast cereals, infant formula and some yoghurts have added vitamin D.







Excerpt from:
www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/expert-answers/vitamin-d-toxicity/faq-20058108
Title: What is vitamin D toxicity, and should I worry about it since I take supplements?
Author: Katherine Zeratsky, R.D., L.D.
Date: Feb. 07, 2018

Vitamin D toxicity, also called hypervitaminosis D, is a rare but potentially serious condition that occurs when you have excessive amounts of vitamin D in your body.

Vitamin D toxicity is usually caused by megadoses of vitamin D supplements - not by diet or sun exposure. That's because your body regulates the amount of vitamin D produced by sun exposure, and even fortified foods don't contain large amounts of vitamin D.

The main consequence of vitamin D toxicity is a buildup of calcium in your blood (hypercalcemia), which can cause nausea and vomiting, weakness, and frequent urination. Symptoms might progress to bone pain and kidney problems, such as the formation of calcium stones.

Treatment includes stopping vitamin D intake and restricting dietary calcium. Your doctor might also prescribe intravenous fluids and medications, such as corticosteroids or bisphosphonates.

Taking 60,000 international units (IU) a day of vitamin D for several months has been shown to cause toxicity. This level is many times higher than the Recommended Dietary Allowance (RDA) for most adults of 600 IU of vitamin D a day. Doses higher than the RDA are sometimes used to treat medical problems such as vitamin D deficiency, but these are given only under the care of a doctor for a specified time frame. Blood levels should be monitored while someone is taking high doses of vitamin D.







Excerpt from:
www.healthline.com/nutrition/vitamin-d-dosage
Title: What Vitamin D Dosage Is Best?
Author: Ryan Raman, MS, RD
Date: October 8, 2017

Another analysis of seventeen studies with over 300,000 people looked at the link between vitamin D intake and heart disease. Scientists found that taking 1,000 IU (25 mcg) of vitamin D daily reduced heart disease risk by 10%.

Based on current research, it seems that consuming 1,000-4,000 IU (25-100 mcg) of vitamin D daily should be ideal for most people to reach healthy vitamin D blood levels.

However, don't consume more than 4,000 IU of vitamin D without your doctor's permission. It exceeds the safe upper limits of intake and is not linked to more health benefits.







Excerpt from:
www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/expert-answers/vitamin-c/faq-20058030
Title: Is it possible to take too much vitamin C?
Author: Katherine Zeratsky, R.D., L.D.
Date: March 18, 2020

Is it possible to take too much vitamin C?
Answer From Katherine Zeratsky, R.D., L.D.

While vitamin C (ascorbic acid) is an essential nutrient, it's possible to have too much of it.

Vitamin C is a water-soluble vitamin that supports normal growth and development and helps your body absorb iron. Because your body doesn't produce or store vitamin C, it's important to include vitamin C in your diet. For most people, an orange or a cup of strawberries, chopped red pepper, or broccoli provides enough vitamin C for the day.

For adults, the recommended daily amount for vitamin C is 65 to 90 milligrams (mg) a day, and the upper limit is 2,000 mg a day. Although too much dietary vitamin C is unlikely to be harmful, megadoses of vitamin C supplements might cause:

- Diarrhea
- Nausea
- Vomiting
- Heartburn
- Abdominal cramps
- Headache
- Insomnia

Remember, for most people, a healthy diet provides an adequate amount of vitamin C.







Excerpts from:
www.mayoclinic.org/drugs-supplements-vitamin-c/art-20363932
Title: Vitamin C
Date: Oct. 18, 2017

Vitamin C (ascorbic acid) is a vitamin your body needs to form blood vessels, cartilage, muscle and collagen in bones. Vitamin C is also vital to your body's healing process.

An antioxidant, vitamin C might help protect your cells against the effects of free radicals - molecules produced when your body breaks down food or is exposed to tobacco smoke and radiation. Free radicals might play a role in heart disease, cancer and other diseases. Vitamin C also helps your body absorb and store iron.

Because your body doesn't produce vitamin C, you need to get it from your diet. Vitamin C is found in citrus fruits, berries, potatoes, tomatoes, peppers, cabbage, Brussels sprouts, broccoli and spinach.

[...]

The recommended daily amount of vitamin C for adult men is 90 milligrams and for adult women is 75 milligrams.

[...]

- Common cold. Taking oral vitamin C supplements won't prevent the common cold. However, there's some evidence that when people who regularly take vitamin C supplements get a cold, the illness lasts fewer days and symptoms are less severe. Starting a vitamin C supplement only after you develop a cold is of no help.

[...]

Safety and side effects

When taken at appropriate doses, oral vitamin C supplements are generally considered safe. Side effects tend to be dose-related. Oral vitamin C supplements can cause:

- Nausea
- Vomiting
- Heartburn
- Inflammation that might damage the esophagus (esophagitis)
- A blockage that keeps food or liquid from passing through your small intestine or large intestine (intestinal obstruction)
- Stomach cramps
- Fatigue
- Headache
- Sleepiness
- Diarrhea
- Insomnia
- Skin flushing

In some people, oral use of vitamin C can cause kidney stones. Long-term use of oral vitamin C supplements over 2,000 milligrams a day increases the risk of significant side effects.







Excerpt from:
texags.com/forums/84/topics/3102444
Title: Clinical Pearls Covid 19 for ER practitioners
Author: nawlinsag
Date: 3/25/20

I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

Clinical course is predictable.

2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.


Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.


Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.


Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.



***************************************************************************************************************************


In uncertain times, we search for facts to provide comfort and clarity. Throw in the power of Texags.com and I should not be so dumbfounded by the run this is getting.


My first expanded lost draft (thanks again MacBook Touch Bar) contained the appropriate hedging, disclaimers, and uncertainty the current understanding of this pandemic deserves. Some of the more concise, unproofread, hastily rewritten original post (OP) presents itself as more definitive instead of "what I think I know". For this, my apologies. I am not performing clinical trials. I am not involved in cohorting and analyzing data. The academic physicians involved in ER, Infectious Disease and Pulmonary Critical Care are likely (hopefully) way beyond my understanding of Covid 19. Furthermore, I fail to appreciate any additional benefit I could provide to Hospital Administrators who have been preparing and communicating with each other for months; or for some already combating this daily.


Basically, several state medical licensing boards are temporarily loosening their independent practice regulations on NPs, PAs, and to a lesser extent Medical Students. I wrote the OP as much for me to collect and organize my thoughts, as it was to provide a jumping-off platform for providers who may find themselves in an ER-like setting and unknowingly be treating Covid 19 patients or will be treating them soon enough. If any of it helps some of my colleagues hit the ground running then that is something too.


The OP was a summary of thoughts from being emersed in Covid 19 for weeks, reading as much as I can, and following up on my own patients. It is not my intention for this to be taken as dogma. I do not have the answers or the algorithm everyone is searching for. I was merely looking to point the handful of people I thought would read it in a clinical direction best I could. What I think I know evolves every day with the presumption it may very well end up markedly different once this pandemic is better understood. I do not know when this crisis will ultimately be arrested, however, I maintain resolute that each one of us can help make that happen. Stay home. Be safe. Find a way not to have to visit grandma.


Thank you to all the well-wishers and good luck to us all.



Sincerely,


NawlinsAg



No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.







Excerpts from:
nypost.com/2020/03/24/new-york-hospitals-treating-coronavirus-patients-with-vitamin-c
Title: New York hospitals treating coronavirus patients with vitamin C
Authors: Lorena Mongelli and Bruce Golding
Date: March 24, 2020

Dr. Andrew G. Weber, a pulmonologist and critical-care specialist affiliated with two Northwell Health facilities on Long Island, said his intensive-care patients with the coronavirus immediately receive 1,500 milligrams of intravenous vitamin C.

Identical amounts of the powerful antioxidant are then readministered three or four times a day, he said.

Each dose is more than 16 times the National Institutes of Health's daily recommended dietary allowance of vitamin C, which is just 90 milligrams for adult men and 75 milligrams for adult women.

The regimen is based on experimental treatments administered to people with the coronavirus in Shanghai, China, Weber said.

"The patients who received vitamin C did significantly better than those who did not get vitamin C," he said.

"It helps a tremendous amount, but it is not highlighted because it's not a sexy drug."

[...]

The vitamin C is administered in addition to such medicines as the anti-malaria drug hydroxychloroquine, the antibiotic azithromycin, various biologics and blood thinners, Weber said.

[...]

As of Tuesday, New York hospitals have federal permission to give a cocktail of hydroxychloroquine and azithromycin to desperately ill patients on a "compassionate care" basis.

[...]

Weber, 34, said vitamin C levels in coronavirus patients drop dramatically when they suffer sepsis, an inflammatory response that occurs when their bodies overreact to the infection.

[...]

A clinical trial on the effectiveness of intravenous vitamin C on coronavirus patients began Feb. 14 at Zhongnan Hospital in Wuhan, China, the epicenter of the pandemic.

The randomized, triple-blind study will involve an estimated 140 participants and is expected to be complete by Sept. 30, according to information posted on the US National Library of Medicine's website.







Excerpt from:
www.healthline.com/nutrition/immune-boosting-supplements
Title: The 15 Best Supplements to Boost Your Immune System Right Now
Author: Jillian Kubala, MS, RD
Date: March 24, 2020

Zinc is a mineral that's commonly added to supplements and other healthcare products like lozenges that are meant to boost your immune system. This is because zinc is essential for immune system function.

Zinc is needed for immune cell development and communication and plays an important role in inflammatory response.

A deficiency in this nutrient significantly affects your immune system's ability to function properly, resulting in an increased risk of infection and disease, including pneumonia.

Zinc deficiency affects around 2 billion people worldwide and is very common in older adults. In fact, up to 30% of older adults are considered deficient in this nutrient.

Numerous studies reveal that zinc supplements may protect against respiratory tract infections like the common cold.

What's more, supplementing with zinc may be beneficial for those who are already sick.

In a 2019 study in 64 hospitalized children with acute lower respiratory tract infections (ALRIs), taking 30 mg of zinc per day decreased the total duration of infection and the duration of the hospital stay by an average of 2 days, compared with a placebo group.

Supplemental zinc may also help reduce the duration of the common cold (15Trusted Source).

Taking zinc long term is typically safe for healthy adults, as long as the daily dose is under the set upper limit of 40 mg of elemental zinc.

Excessive doses may interfere with copper absorption, which could increase your infection risk.

SUMMARY
Supplementing with zinc may help protect against respiratory tract infections and reduce the duration of these infections.







Excerpts from:
www.nhs.uk/conditions/vitamins-and-minerals/others
Title: Vitamins and minerals
Date: 3 March 2017

Zinc helps with:

- making new cells and enzymes
- processing carbohydrate, fat and protein in food
- wound healing

[...]

Good sources of zinc include:

- meat
- shellfish
- dairy foods - such as cheese
- bread
- cereal products - such as wheatgerm

[...]

The amount of zinc you need is about:

- 9.5mg a day for men (aged 19 to 64 years)
- 7mg a day for women

You should be able to get all the zinc you need from your daily diet.

[...]

Taking high doses of zinc reduces the amount of copper the body can absorb. This can lead to anaemia and weakening of the bones.

[...]

Don't take more than 25mg of zinc supplements a day unless advised to by a doctor.







Excerpts from:
www.nhs.uk/medicines/salbutamol-inhaler
Title: Salbutamol inhaler
Date: 23 October 2018

Salbutamol is used to relieve symptoms of asthma and COPD such as coughing, wheezing and feeling breathless. It works by relaxing the muscles of the airways into the lungs, which makes it easier to breathe.

Salbutamol comes in an inhaler (puffer). Salbutamol inhalers are usually blue.

Salbutamol is sometimes given as tablets, capsules or syrup for people who can't use an inhaler very well.

It can also be given using a nebuliser, but this is usually only if you have severe asthma or COPD. A nebuliser is a machine that helps you breathe in your medicine as a mist, using a mask or a mouthpiece. You can use a nebuliser in hospital or you may be given one to manage your condition at home.

[...]

The normal way for adults and children to use their inhaler is:

- 1 or 2 puffs of salbutamol when you need it
- up to a maximum of 4 times in 24 hours (regardless of whether you have 1 puff or 2 puffs at a time)

[...]

In a sudden asthma attack you can take more salbutamol, up to 10 puffs, but you should wait 30 seconds and always shake the inhaler between doses. You can repeat this dose 10 minutes later.

[...]

For treating severe asthma attacks, salbutamol can be given through a nebuliser. A nebuliser is a machine that delivers the medicine as a mist inhaled through a face mask. This will probably be given to you by your doctor.


What if I take too much?

You may notice that your heart beats more quickly than normal and that you feel shaky. These side effects aren't dangerous, as long as you don't also have chest pain. They usually go away within 30 minutes or a few hours at most.

[...]

More than 1 in 100 people have these side effects after taking 1 or 2 puffs of their inhaler:

- feeling shaky
- faster heartbeat for a short while (but no chest pain)
- headaches
- muscle cramps

These side effects aren't dangerous and they should gradually improve as your body gets used to salbutamol.


Serious side effects

It happens rarely, but some people may have very serious side effects when taking salbutamol.

Call a doctor straight away if you get:

- muscle pain or weakness, muscle cramps, or a heartbeat that doesn't feel normal - this can be a sign of low potassium levels
- very bad dizziness or you pass out
- chest pain, especially if you also have a fast heartbeat or your heartbeat doesn't feel normal
- a very bad headache







Excerpt from:
www.nhs.uk/medicines/aspirin-for-pain-relief
Title: Aspirin for pain relief
Date: 15 November 2018

NHS coronavirus advice
There is currently no strong evidence that non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen or aspirin for pain relief can make coronavirus (COVID-19) worse.

But until we have more information, take paracetamol to treat the symptoms of coronavirus, unless your doctor has told you paracetamol is not suitable for you.

If you have no coronavirus symptoms and regularly take aspirin for pain relief, carry on taking it as usual. If you develop coronavirus symptoms, ask your doctor about changing to paracetamol instead.

Updated: 20 March 2020







Excerpts from:
www.verywellhealth.com/when-a-ventilator-is-necessary-3156902
Title: When a Ventilator Is Necessary
Author: Jennifer Whitlock, RN, MSN, FN
Medically reviewed by Michael Menna, DO
Date: March 30, 2020

A ventilator, also known as a respirator or breathing machine, is a medical device that provides a patient with oxygen when they are unable to breathe on their own. The ventilator gently pushes air into the lungs and allows it to come back out like the lungs would typically do when they are able.

Ventilators are currently essential for critically ill COVID-19 patients. When the virus enters the lower respiratory tract, it has the ability to damage alveoli-air-filled sacs in the lungs that introduce oxygen to the bloodstream. Fluid begins to fill the alveoli instead of air, depriving oxygen supply to all parts of the body. A ventilator becomes the best option to quickly and effectively get oxygen back into the body while the lungs attempt to heal.

[...]

Intubation

In order to be placed on a ventilator, the patient must be intubated. This means having an endotracheal tube placed in the mouth or nose and threaded down into the airway. This tube has a small inflatable gasket which is inflated to hold the tube in place. The ventilator is attached to the tube and the ventilator provides "breaths" to the patient.


Sedation

If a patient is on the ventilator after surgery, medication is often given to sedate the patient. This is done because it can be upsetting and irritating to the patient to have an endotracheal tube in place and feel the ventilator pushing air into the lungs. The goal is to keep the patient calm and comfortable without sedating them so much that they cannot breathe on their own and be removed from the ventilator.


Weaning

Weaning is the term used for the process of removing someone from the ventilator. Most surgery patients are removed from the ventilator quickly and easily. They may be provided a small amount of nasal oxygen to make the process easier, but they are typically able to breathe without difficulty.

Patients who are not able to be removed from the ventilator immediately after surgery may require weaning, which is a process where the ventilator settings are adjusted to allow the patient to attempt to breathe on their own, or for the ventilator to do less work and the patient to do more. This may be done for days or even weeks, gradually allowing the patient to improve their breathing.

CPAP, or continuous positive airway pressure, is a ventilator setting that allows patients to do the work of breathing with the ventilator available to help if the patient isn't doing well.

[...]

Many patients do complain of a sore throat after being intubated, so throat sprays, lozenges or numbing medications may be used if the patient can tolerate them and they can be used safely.

[...]

Patient care for the individual on a ventilator often consists of preventing infection and skin irritation. These patients are almost always in an intensive care unit (ICU) and receive constant monitoring and attention.

[...]

Patient Care

Patient care for the individual on a ventilator often consists of preventing infection and skin irritation. These patients are almost always in an intensive care unit (ICU) and receive constant monitoring and attention.

Tape or a strap is used to keep the endotracheal tube in place, this is changed when dirty and the tube is regularly moved from one side of the mouth to the other. Moving the tube is done to prevent skin irritation and breakdown from the tube rubbing against the tissues of the mouth.

Mouth care is frequently performed to prevent infection. The mouth is often dry, so the mouth is cleaned and moistened to protect the teeth and reduce any harmful bacteria that could make their way into the lungs and cause pneumonia.

Oral secretions are suctioned from the mouth to prevent them from draining into the lungs and causing pneumonia. Secretions from the lungs are suctioned as the patient will be unable to cough these secretions up while on the ventilator.

Patients who require a ventilator are often too sick or weak to reposition themselves, so frequent turning is also part of routine care.

Breathing treatments are routinely provided by respiratory therapy or nursing staff, to help keep the airways open, thin secretions that may be present and treat any lung conditions that the patient may have.


Long-Term Care

For patients who are unable to be weaned from the ventilator, a tracheostomy may be necessary.

An endotracheal tube should not be left in place for more than a few weeks as it can eventually cause permanent damage to the vocal cords or windpipe and can make ventilator weaning more difficult.

For patients who are expected to be on a ventilator long term, a surgically created opening is made in the neck and the ventilator is attached there, rather than functioning through the tube placed in the mouth.







Excerpt from:
www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
Title: Groups at Higher Risk for Severe Illness
Date: April 2, 2020

Based on what we know now, those at high-risk for severe illness from COVID-19 are:

- People 65 years and older
- People who live in a nursing home or long-term care facility

People of all ages with underlying medical conditions, particularly if not well controlled, including:

- People with chronic lung disease or moderate to severe asthma
- People who have serious heart conditions
- People who are immunocompromised
- Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
- People with severe obesity (body mass index [BMI] of 40 or higher)
- People with diabetes
- People with chronic kidney disease undergoing dialysis
- People with liver disease







Excerpt from:
www.telegraph.co.uk/global-health/science-and-disease/intensive-care-doctors-question-overly-aggressive-use-ventilators
Author: Paul Nuki, Global Health Security Editor, London
Date: 9 April 2020

British and American intensive care doctors at the front line of the coronavirus crisis are starting to question the aggressive use of ventilators for the treatment of patients.

In many cases they say the machines, which are highly invasive and require the patient to be rendered unconscious, are being used too early and may cause more harm than good. Instead they are finding that less invasive forms of oxygen treatment through face masks or nasal cannulas work better for patients, even those with very low blood oxygen readings.

Dr Ron Daniels, a consultant in critical care at University Hospitals Birmingham NHS Foundation Trust, on Thursday confirmed reports from US medics that he and other NHS doctors were revising their view of when ventilators should be used.

At the heart of the issue was the "bizarre" and "frankly baffling" phenomenon of Covid-19 patients presenting with catastrophically low blood oxygen levels but few other ill effects.

"We've had patients with oxygen measures of just 5 kilopascals [70-75 per cent of normal] who are talking to us normally and have no obvious air hunger [gasping for breath]", said Dr Daniels. "Normally anyone with numbers like that would be ventilated but increasingly with Covid patients we are considering holding back.

"The question everyone is asking is, do we treat symptoms or do we treat the numbers? It's a good question and one that I think doctors everywhere are now grappling with."

The initial recommendations from doctors in China and Italy were to ventilate Covid patients early and aggressively, with the so-called "PEEP" pressure on the machines turned up high so their lungs did not contract when they exhaled.

"The initial message was treat as if you were treating for acute respiratory distress syndrome (ARDS) with a high PEEP," said Daniels. "But now we are becoming braver. We are tolerating much lower blood oxygen levels and using lower pressures. We are learning as we go along".

The alternative to mechanical ventilation is oxygen treatment delivered via a mask or a nasal cannula or via a non-invasive high flow device. This is the sort of treatment the Prime Minister Boris Johnson is said to be receiving in an intensive care unit at St Thomas's hospital London. His blood oxygen levels are not known.

Increasingly doctors in the UK, America and Europe are using these less invasive measures and holding back on the use of mechanical ventilation for as long as possible.

"Increasingly we are making the decision to focus on symptoms rather than numbers - predicting the point of fatigue where the patient is struggling to breath independently," said Dr Daniels.

Doctors in Italy and Germany wrote to the American Journal of Respiratory and Critical Care Medicine last week making a similar point. They urged other doctors to be "patient" with Covid patients, arguing for "gentle ventilation" wherever possible.

Invasive ventilation is never a good option for any patient if it can be avoided. It can result in muscle wastage around the lungs and makes secondary infections more likely. It also requires a cocktail of drugs which themselves can prove toxic and lead to organ failure.

It is not known why Covid-19 allows some patients to tolerate such low blood oxygen readings without air hunger or obvious confusion. One clue may be that patients are still able to exhale carbon dioxide - a toxin - through their lungs even if they are having difficulty absorbing oxygen.

"The patients in front of me are unlike any I've ever seen," one American doctor working in a Brooklyn hospital told the specialist health publication STAT this week. "They looked a lot more like they had altitude sickness than pneumonia."

Dr Daniels agreed that there were similarities with altitude sickness, itself a potentially fatal condition. "We've seen a lot of headache and dizziness", he noted.

While doctors are not using mechanical ventilation as aggressively now as they were at the start of the crisis, the machines remain a last resort for many Covid patients. Survival rates are not as good as for those with other forms of viral pneumonia but ventilators are nevertheless still saving many lives.

Intensive care units are also much more than just a ventilator. Even where patients, like the Prime Minister, are receiving more gentle forms of oxygen treatment their vital signs need to be extremely carefully.

"It's about having highly skilled staff to care for the patients and a whole plethora of ancillary equipment and medications beyond the ventilator itself," said Dr Daniels.







Excerpts from:
www.verywellhealth.com/definition-of-expectorants-914780
Title: What to Know About Expectorants
Author: Deborah Leader, RN
Date: January 29, 2020

An expectorant is a type of cough medicine that thins and loosens mucus. These medications are typically used for managing the effects of chest congestion, especially when symptoms are caused by persistent mucus.

Guaifenesin, the most commonly used expectorant, is the active ingredient in Mucinex and Robitussin. In general, expectorants are available over-the-counter (OTC) in liquid, pill, and tablet forms.

Expectorants are part of the mucoactive class of drugs (i.e., those that clear mucus from the airways).


Uses

Expectorants are commonly used for management of the symptoms of acute (short-term) respiratory tract infections, like the common cold, pneumonia, or bronchitis.

These infections can cause a build-up of phlegm in your throat or lungs. It is often difficult to cough up this thick mucus, and you can develop a nagging cough and chest discomfort due to mucus accumulation.

Expectorants are designed to thin the respiratory secretions in your airways so that you can cough up excessive mucus more effectively. These medications do this by lubricating the airway passages.

Coughing up phlegm reduces discomfort from chest congestion. Coughing up debris and infectious material (like bacteria and viruses) may also lower the risk of infection.







Excerpts from:
www.nejm.org/doi/full/10.1056/NEJMoa2007016
Title: Compassionate Use of Remdesivir for Patients with Severe Covid-19
Authors: Jonathan Grein, M.D., Norio Ohmagari, M.D., Ph.D., Daniel Shin, M.D., George Diaz, M.D., Erika Asperges, M.D., Antonella Castagna, M.D., Torsten Feldt, M.D., Gary Green, M.D., Margaret L. Green, M.D., M.P.H., Francois-Xavier Lescure, M.D., Ph.D., Emanuele Nicastri, M.D., Rentaro Oda, M.D., et al.
Date: April 10, 2020

METHODS

We provided remdesivir on a compassionate-use basis to patients hospitalized with Covid-19, the illness caused by infection with SARS-CoV-2. Patients were those with confirmed SARS-CoV-2 infection who had an oxygen saturation of 94% or less while they were breathing ambient air or who were receiving oxygen support. Patients received a 10-day course of remdesivir, consisting of 200 mg administered intravenously on day 1, followed by 100 mg daily for the remaining 9 days of treatment.

[...]

CONCLUSIONS

In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%). Measurement of efficacy will require ongoing randomized, placebo-controlled trials of remdesivir therapy. (Funded by Gilead Sciences.)







Excerpts from:
www.healthline.com/health/endotracheal-intubation
Title: Endotracheal Intubation
Author: Corinna Underwood
Medically reviewed by Judith Marcin, MD
Date: December 12, 2017

Intubation risks

There are some risks related to intubation, such as:

- injury to teeth or dental work
- injury to the throat or trachea
- a buildup of too much fluid in organs or tissues
- bleeding
- lung complications or injury
- aspiration (stomach contents and acids that end up in the lungs)

[...]

How do I prepare for endotracheal intubation?

Intubation is an invasive procedure and can cause considerable discomfort. However, you'll typically be given general anesthesia and a muscle relaxing medication so that you don't feel any pain. With certain medical conditions, the procedure may need to be performed while a person is still awake. A local anesthetic is used to numb the airway in order to lessen the discomfort. Your anesthesiologist will let you know prior to intubation if this situation applies to you.







Excerpt from:
www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30165-X/fulltext
Title: Understanding pathways to death in patients with COVID-19
Authors: Jean-Louis Vincent, Fabio S Taccone
Date: April 06, 2020

Currently reported case fatality rates vary from 1% to more than 7%, but these values must be interpreted with caution. For example, where massive screening has been performed in the whole population (eg, in South Korea and Switzerland), overall case fatality rates of less than 1% have been reported, because the denominator included many mild or asymptomatic cases. However, in countries where only people requiring hospital admission are being screened (eg, Italy and Spain), case fatality rates have exceeded 5%, because the denominator is much smaller.







Excerpt from:
adc.bmj.com/content/104/1/91
Title: Milk, mucus and myths
Author: Ian M Balfour-Lynn
Date: September 6, 2018

Conclusions

While certainly the texture of milk can make some people feel their mucus and saliva is thicker and harder to swallow, there is no evidence (and indeed evidence to the contrary) that milk leads to excessive mucus secretion. Milk is an important source of calories, calcium and vitamins for children. The milk-mucus myth needs to be rebutted firmly by healthcare workers.