COVID-19: Therapy

General measures

  • Hand washing incl. forearms (also applies to the face if you have been with people indoors): see this under Prevention/Preventive MeasuresNote: The German Dermatological Society (DDG) recommends disinfecting hands in pandemic times instead of too much washing with soap. However, after each disinfect and after each hand washing the skin should be creamed with a care product to support the regeneration of the skin barrier.
  • Hygiene measures in practice:
    • Separate patient in separate room with mouth–nose protection.
    • Physician: put on protective clothing, i.e. protective gown, gloves, protective goggles (esp. for activities in which large quantities of aerosols may be generated; e.g. bronchoscopy/lung endoscopy), tight-fitting respirator (protection level at least FFP2 mask; ideal: FFP3 mask).
  • SARS-CoV-2 infected without risk factors for complications (such as immunosuppression, relevant chronic underlying diseases, advanced age) with the ability to care for themselves (no need for care!) Can be cared for under medical supervision at home (= quarantine at home). See also for this prognosis score CRB-65 score under “Physical examination“: lethality risk (mortality risk) and measuresNote on quarantine: a 14-day monitoring of possibly infected persons probably overlooks very few patients, since according to a study 97.5% of infected patients were symptomatic within 11, 5 days.Meanwhile, in Germany, the federal and state governments have agreed to set the time interval of quarantine at home to 10 days as a rule.
  • SARS-CoV-2 infected persons with risk factors for complications (see above) must be admitted directly to a hospital.
    • Affected persons must be isolated: Isolation room if possible with anteroom/lock, otherwise single room with own wet cell.
  • If necessary, intensive medical therapy (eg, with evidence of respiratory failure / inadequate respiration resulting in inadequate gas exchange: dyspnea (shortness of breath) with increased respiratory rate (> 30/min), thereby hypoxemia (lack of oxygen in the blood) in the foreground):
    • Ventilation therapy [guidelines: recommendations for intensive care therapy of patients with COVID-19].
      • High-flow oxygen therapy (HFOT): delivery of oxygen along with compressed air and exhaust humidification (note: HFOT results in aerosol formation)Oxygen volume note: conventional oxygen therapy: -16 l/min; HFOT: -60 l/min
        • In patients with acute hypoxic respiratory failure (drop in arterial blood oxygen partial pressure, but carbon dioxide partial pressure can still be compensated), oxygenation (saturation of tissues with oxygen) with a respiratory helmet or face mask reduces patient mortality compared with standard oxygen administration. Furthermore, helmet, mask, and nasal high-flow oxygenation reduce the risk of intubation (insertion of a tube (a hollow probe) into the trachea/trachea).
      • Preferably intubation and invasive ventilation: patients with more severe hypoxemia (PaO2/FIO2 ≤ 200 mmHg).
      • For patients with ARDS (Adult (Acute) Respiratory Distress Syndrome): lung-protective mechanical ventilation with tidal volume 5-8 ml/kg bw, low peak pressure (< 30 mbar) and PEEP (“Positive End-Expiratory Pressure”, English : “positive end-expiratory pressure”) 9-12 mbar; early spontaneous breathing (under BIPAP; (an upper and lower ventilation pressure is set and the change between both pressure levels corresponds to inspiration (inhalation) and expiration (from breathing); engl. “Biphasic Positive Airway Pressure”)Note!
        • To ensure adequate oxygenation (saturation of tissues with oxygen), an SpO2 ≥ 90% is recommended.
        • Lung-protective ventilation (lung-protective ventilation) is generally to be classified as more important than the immediate correction of hypoxemia (oxygen deficiency).
        • COVID-19 patients with respiratory failure benefit from prone positioning (16 hours).
    • Fluid restriction in acute hypoxemic respiratory failure (esp. in the absence of shock or tissue diminished perfusion).
    • Positioning therapy – with the upper body elevated; if necessary, intermittent prone position.
    • Drug therapy (inhaled vasodilators).
    • Other options include ECMO (extracorporeal membrane oxygenation), pECLA (pumpless extracorporeal lung assist), or HFOV (high-frequency oscillation ventilation)

Further notes

  • The mechanical variables of mechanical ventilation (mechanical power: product of respiratory rate, tidal volume, peak pressure, and drive pressure) are among the factors that determine mortality (death rate) in patients with respiratory insufficiency (disruption of lung gas exchange with abnormally altered blood gas levels). A dose-response relationship has been demonstrated. The mechanical power parameters described are surrogate parameters; alveolar pressure (pressure in the alveoli) is crucial for lung damage caused by mechanical ventilation.CONCLUSION: Limiting drive pressure and mechanical power probably reduces mortality in ventilated patients.
  • The mortality rate of COVID-19 patients undergoing extracorporeal membrane oxygenation (ECMO) is less than 40% according to presented experience from a worldwide patient registry.

ECDC recommendations for contact management

  • Close contact of a probable or confirmed case is defined as: A person living in the same household as a COVID-19 disease case.
  • A person who has had direct physical contact with a COVID-19 disease case (e.g., shaking hands).
  • A person who has had unprotected direct contact with infectious secretions from a COVID-19 disease case (e.g., coughing, touching used paper tissues with bare hands).
  • A person who has had direct contact >15 minutes with a COVID-19 disease case within 2 meters.
  • A person who was in an enclosed environment (e.g., classroom, meeting room, hospital waiting room, etc.) with a COVID-19 disease case ≥ 15 minutes and within 2 meters.
  • A health care worker (HCW) or other person directly treating a COVID-19 disease case, or laboratory workers testing specimens from a COVID-19 case without recommended PPE (“personal protective equipment”; protective clothing) or with a possible PPE violation.
  • A contact on an aircraft seated within two seats (in any direction) of the COVID-19 disease case, travel companions or caregivers, and crewmembers serving in the section of the aircraft where the index case was located.

The epidemiologic link may have occurred in the case under consideration within 14 days before the onset of illness.

Conventional nonsurgical therapeutic methods

Vaccinations

The following vaccinations are advised, as SARS-CoV-2 infection may be associated with other infections:

  • Pneumococcal vaccinationNote: In patients with immunosuppression, the STIKO advises sequential vaccination, with PCV13 (conjugate vaccine) given first and PSV23 (23-valent polysaccharide vaccine) given 6-12 months later. This strategy has significantly higher protective efficacy than when vaccinated with PSV23 alone.
  • Influenza vaccination (flu shot).
  • Herpes zoster vaccination

Nutritional medicine

  • Nutritional counseling based on nutritional analysis
  • Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
    • Daily total of 5 servings of fresh vegetables and fruits (≥ 400 g; 3 servings of vegetables and 2 servings of fruits).
    • Once or twice a week fresh sea fish, i.e. fatty marine fish (omega-3 fatty acids) such as salmon, herring, mackerel.
    • High-fiber diet (whole grains, vegetables).
  • Observance of the following special nutritional recommendations:
    • Patients with immunodeficiency / susceptibility to infection, for example, chemotherapy, must be extremely vigilant and careful in everyday life. For example, foods that are not sterilized and thus contain many pathogens (e.g., N. Listeria) should be avoided.The following rules should be observed in food selection and preparation:
      • Avoid: Raw or only soft-boiled eggs, as well as fried eggs and dishes containing raw eggs (tiramisu, dishes with beaten egg whites); raw milk or raw milk products (raw milk cheese).
      • All dishes should be cooked at least 60 ° C for at least 10 minutes.
      • Opened food should be used up or the rest thrown away.
      • Ice cream only from the freezer; soft ice cream should not be eaten, as it often contains pathogens.
    • Diet rich in:
  • See also under “Therapy with micronutrients (vital substances)” – Taking a suitable dietary supplement.
  • Detailed information on nutritional medicine you will receive from us.

Sports Medicine

  • Because COVID-19 can also damage the myocardium (heart muscle), recovering patients cannot immediately resume (competitive) sports. The following are the main recommendations for sports after COVID-19:
    • Asymptomatic infected patients: Abstain from exercise until 2 weeks after positive test result. Note whether symptoms or evidence of worsening do occur. If not, training can be started slowly after 2 weeks.
    • Outpatient COVID-19 patients with mild to moderate symptoms: suspend exercise training even after symptoms have disappeared for at least 2 more weeks. This should be followed by a comprehensive cardiac evaluation. This includes an hsTn (high-sensitivity troponin I), 12-lead ECG, and echocardiography (cardiac echo).
      • If cardiac test results are unremarkable, a slow return to exercise can be made. Attention should be paid to whether symptoms or evidence of worsening occur.
      • If examination results are abnormal, experts recommend following the “return to play” guidelines for myocarditis patients (patients with heart muscle inflammation).
    • COVID-19 inpatients with severe symptoms: if in-hospital examinations were unremarkable, a medical evaluation to determine exercise capacity may be performed after the earliest 2 weeks of symptom relief. If a cardiac evaluation was not performed in the hospital, it should be followed up.
      • If cardiac examination results are unremarkable, athletic activity can be resumed slowly and under medical supervision.
      • If examination results are abnormal, experts recommend following the “return to play” guidelines for myocarditis patients (patients with heart muscle inflammation).

Rehabilitation

  • COVID-19 survived disease is often associated with an arduous journey back to life: rehabilitative measures are not infrequently required in previously severely ill patients.