COVID-19-associated pneumonia: Difference between revisions

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__NOTOC__
__NOTOC__  
{{Main article|COVID-19}}
{{SI}}
{{SI}}
'''For COVID-19 frequently asked inpatient questions, click [[COVID-19 frequently asked inpatient questions|here]]'''<br>
'''For COVID-19 frequently asked outpatient questions, click [[COVID-19 frequently asked outpatient questions|here]]'''<br>'''For COVID-19 patient information, click [[COVID-19 (patient information)|here]]'''


{{CMG}}; {{AE}} {{Usman Ali Akbar}}
{{CMG}}; {{AE}} {{Usman Ali Akbar}}


{{SK}}  
{{SK}}2019 novel coronavirus disease, COVID19, Wuhan virus, L type COVID pneumonia, H type Pneumonia 


==Overview==
==Overview==
 
In December 2019, a novel coronavirus was detected in [[pneumonia]] patients in the Chinese city of Wuhan. The novel coronavirus was later named as [[2019-nCoV|2019-nCoV.]] Since it was identified, [[pneumonia]] appears to be the most frequent manifestation of infection. Despite mimicking the symptoms and criteria of Berlin's definition of [[Acute respiratory distress syndrome|ARDS]], COVID-19 pneumonia is a distinct disease with features including severe [[hypoxemia]] often associated with the normal or near-normal respiratory system [[compliance]].
* The severe acute respiratory syndrome caused by SARS-CoV-2 is the cause of global pandemic that began in the chinese city of Wuhan late 2019.
[[File:Overview-pneumonia.jpg|600px|center]]
* In December 2019, a novel corona virus was detected in pneumonia patients which was later named as 2019-nCoV.
* Pneumonia appears to be the most frequent manifestation of infection.
*This pneumonia has been named as novel corona virus infected pneumonia (NCIP).
*


==Historical Perspective==
==Historical Perspective==


* In December 2019, there were case reports of cluster of acute respiratory illness in the Wuhan , Hubei Province,China.  
* In December 2019, there were case reports of a cluster of acute respiratory illness in the [[Wuhan coronavirus|Wuhan,]] Hubei Province, China.
* In January 2020, novel coronavirus was identified in the the samples of bronchoalveolar lavage fluid from a patient in Wuhan.
* In January 2020, novel coronavirus was identified in the samples of [[bronchoalveolar lavage]] fluid from a patient in Wuhan.<ref name="Wang Hu Hu Zhu p=1061">{{cite journal | last=Wang | first=Dawei | last2=Hu | first2=Bo | last3=Hu | first3=Chang | last4=Zhu | first4=Fangfang | last5=Liu | first5=Xing | last6=Zhang | first6=Jing | last7=Wang | first7=Binbin | last8=Xiang | first8=Hui | last9=Cheng | first9=Zhenshun | last10=Xiong | first10=Yong | last11=Zhao | first11=Yan | last12=Li | first12=Yirong | last13=Wang | first13=Xinghuan | last14=Peng | first14=Zhiyong | title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China | journal=JAMA | publisher=American Medical Association (AMA) | volume=323 | issue=11 | date=2020-03-17 | issn=0098-7484 | doi=10.1001/jama.2020.1585 | page=1061}}</ref>
* Later this has been confirmed as the cause of novel corona virus infected pneumonia.
* Later this has been confirmed as the cause of novel corona virus-infected [[pneumonia]].
* The first cases were reported by Huang et al in which most of the patients had history of exposure to the seafood whole sale market.  
* The first cases were reported by Huang et al in which most of the patients had a history of exposure to the seafood wholesale market.  
* There have been no effective therapies or vaccines available for NCIP as of yet.
* There have been no effective therapies or [[Vaccine|vaccines]] available for NCIP as of yet.
*In May 2020, it was postulated that there is also a third distinctive type. This phenotype usually mimics the patchy [[Acute respiratory distress syndrome|ARDS]] phenotype.


==Classification==
==Classification==
There is no established system for the classification of coronavirus infected pneumonia. Based on the detailed observation of case reports and case series, it has been found that COVID-19 patients differ in their presentation at the emergency department based on three factors.


1) The severity of infection, host immune response, preserved physiological reserve and associated comorbidities.
* There is no established system for the classification of [[coronavirus]] infected pneumonia. Based on the detailed observation of case reports and case series, it has been found that COVID-19 patients differ in their presentation in the emergency department based upon the following three factors:


2) Response of patient to the hypoxemia in terms of ventilator  
# The severity of infection, host [[immune response]], preserved physiological reserve, and associated comorbidities.
# Response of patient to the [[hypoxemia]] in terms of ventilator
# the time between the presentation of patient to the emergency department and the onset of the disease.


3) the time between the presentation of patient to the emergency department and the onset of the disease.
* Based on these three factors, NCIP has been divided COVID-19 associated pneumonia into the following two different [[phenotypes]]<ref name="wikidoc 2020">{{cite web | title=COVID-19-associated pneumonia | website=wikidoc | date=2020-03-17 | url=https://www.wikidoc.org/index.php/COVID-19-associated_pneumonia | access-date=2020-07-13}}</ref> :
 
Based on these factors, NCIP has been divided into three different phenotypes.  
<br />
{| class="wikitable"
{| class="wikitable"
|+
|+
Line 38: Line 37:
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|COVID‑19 pneumonia, Type H }}  
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|COVID‑19 pneumonia, Type H }}  
|-
|-
|Low elastance
|Low [[elastance]]
|High elastance  
|High [[elastance]]
|-
|-
|Low ventilation to perfusion ratio
|Low ventilation to perfusion ratio
|High Left to right shunt  
|High Left to right shunt  
|-
|-
|Low lung weight  
|Low lung [[weight]]
|High lung weight  
|High lung [[weight]]
|-
|-
|Low lung recruit ability.
|Low lung recruitability.
|High lung recruitability  
|High lung recruitability  
|}
|}
The H type pattern has been reported to present in 20-30 % patients in one case series. It usually fits the criteria of severe ARDS or progresses rapidly towards ARDS. <br /><br />
 
* The H type pattern has been reported to present in 20-30 % patients in one case series. It usually fits the criteria of severe [[Acute respiratory distress syndrome|ARDS]] or progresses rapidly towards [[Acute respiratory distress syndrome|ARDS]].<ref name="wikidoc 2020">{{cite web | title=COVID-19-associated pneumonia | website=wikidoc | date=2020-03-17 | url=https://www.wikidoc.org/index.php/COVID-19-associated_pneumonia | access-date=2020-07-13}}</ref>
*In May 2020, it was postulated that there is also a third distinctive type. This phenotype usually mimics the patchy [[Acute respiratory distress syndrome|ARDS]] phenotype.


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
The exact pathogenesis behind [[COVID-19|COVID-19 associated pneumonia]] is not yet fully understood.
 
OR
 
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
 
OR
 
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
 
OR
 
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.


OR
* COVID-19 usually express [[Transmembrane protein|trans-membrane]] [[Glycoprotein|glycoproteins]] which are called "spike proteins" that allow the [[virus]] to attach itself to the target organ and enter into the cell <ref name="Yuki Fujiogi Koutsogiannaki 2020 p=108427">{{cite journal | last=Yuki | first=Koichi | last2=Fujiogi | first2=Miho | last3=Koutsogiannaki | first3=Sophia | title=COVID-19 pathophysiology: A review | journal=Clinical Immunology | publisher=Elsevier BV | volume=215 | year=2020 | issn=1521-6616 | doi=10.1016/j.clim.2020.108427 | page=108427}}</ref>
* Spike proteins bind to surface [[Angiotensin-converting enzyme|angiotensin converting enzyme]] 2 (ACE2) receptors. Specifically, the RBD of the S protein of SARS-CoV-2 recognizes ACE2 [[receptors]].
* ACE2  is predominately expressed on [[Pneumocytes|type II pneumocytes]]. Other proteins such as TMPRSS2 is also required for complete binding and transmissibility.
* TMPRSS2 cleaves the S protein and results into the [[Fusion mechanism|fusion]] of the viral and host cell membrane.<ref name="Glowacka Bertram Muller Allen pp. 4122–4134">{{cite journal | last=Glowacka | first=I. | last2=Bertram | first2=S. | last3=Muller | first3=M. A. | last4=Allen | first4=P. | last5=Soilleux | first5=E. | last6=Pfefferle | first6=S. | last7=Steffen | first7=I. | last8=Tsegaye | first8=T. S. | last9=He | first9=Y. | last10=Gnirss | first10=K. | last11=Niemeyer | first11=D. | last12=Schneider | first12=H. | last13=Drosten | first13=C. | last14=Pohlmann | first14=S. | title=Evidence that TMPRSS2 Activates the Severe Acute Respiratory Syndrome Coronavirus Spike Protein for Membrane Fusion and Reduces Viral Control by the Humoral Immune Response | journal=Journal of Virology | publisher=American Society for Microbiology | volume=85 | issue=9 | date=2011-02-16 | issn=0022-538X | doi=10.1128/jvi.02232-10 | pages=4122–4134}}</ref>
* The virus [[Replication|replicates]] itself in the target cell using [[RNA dependent RNA polymerase|RNA dependent RNA polymerase.]]
* Lungs seems to be more vulnerable to the [[SARS-CoV-2]] because of the large surface area.
* Direct lung injury leading to release of various [[cytokines]] such as (IL)–1β, [[IL-2]], [[Interleukin 6|IL-6]], [[Interleukin 7|IL-7]], [[Interleukin 12|IL-12]], IL-18, [[Tumour necrosis factor|tumor necrosis factor]] (TNF)–α, [[Interferon-gamma|interferon]] (IFN)–γ, and [[granulocyte colony-stimulating factor]] (GCSF) initiates local inflammatory response and is responsible for the pulmonary manifestations of COVID-19.<ref name="Costela-Ruiz Illescas-Montes Puerta-Puerta Ruiz 2020 p.">{{cite journal | last=Costela-Ruiz | first=Víctor J. | last2=Illescas-Montes | first2=Rebeca | last3=Puerta-Puerta | first3=Jose M. | last4=Ruiz | first4=Concepción | last5=Melguizo-Rodríguez | first5=Lucia | title=SARS-CoV-2 infection: The role of cytokines in COVID-19 disease | journal=Cytokine & Growth Factor Reviews | publisher=Elsevier BV | year=2020 | issn=1359-6101 | doi=10.1016/j.cytogfr.2020.06.001 | page=}}</ref>
* This leads to a modest local subpleural [[interstitial edema]] (ground glass lesions) at the interfaces between lung structures
* Vasoplegia results which further accounts for severe [[Hypoxemia|hypoxemia.]]


[[File:COVID-pneumonia-wikidoc.jpg|600px|center]]


[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
==Differentiating COVID-19-associated pneumonia from other Diseases==
 
*For further information on COVID-19-associated pneumonia [[COVID-19-associated pneumonia differential diagnosis|click here]].
OR
*To view the COVID-19 differential diagnosis [[COVID-19-associated differential diagnosis|click here]].  
 
The progression to [disease name] usually involves the [molecular pathway].
 
OR
 
The pathophysiology of [disease/malignancy] depends on the histological subtype.
 
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
 
OR
 
Common causes of [disease] include [cause1], [cause2], and [cause3].
 
OR
 
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
 
==Differentiating COVID-19-associated encephalopathy from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
OR
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
Patients of all age groups may develop [disease name].
OR
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
OR
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
OR
[Chronic disease name] is usually first diagnosed among [age group].
OR
[Acute disease name] commonly affects [age group].


{| class="wikitable"
|+Incidence/Prevalence of COVID-19 Associated Pneumonia
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Date Published}}
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Author}}
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Country}}
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Total Number Of Patients}}
!style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Incidence/Prevalence}}
|-
|01 June,2020
|San-Juan Rafael.  <ref name="San-Juan Barbero Fernández-Ruiz López-Medrano 2020 p=100407">{{cite journal | last=San-Juan | first=Rafael | last2=Barbero | first2=Patricia | last3=Fernández-Ruiz | first3=Mario | last4=López-Medrano | first4=Francisco | last5=Lizasoáin | first5=Manuel | last6=Hernández-Jiménez | first6=Pilar | last7=Silva | first7=José Tiago | last8=Ruiz-Ruigómez | first8=María | last9=Corbella | first9=Laura | last10=Rodríguez-Goncer | first10=Isabel | last11=Folgueira | first11=María Dolores | last12=Lalueza | first12=Antonio | last13=Batllori | first13=Emma | last14=Mejía | first14=Inma | last15=Forcén | first15=Laura | last16=Lumbreras | first16=Carlos | last17=García-Burguillo | first17=Antonio | last18=Galindo | first18=Alberto | last19=Aguado | first19=José María | title=Incidence and clinical profiles of COVID-19 pneumonia in pregnant women: A single-centre cohort study from Spain | journal=EClinicalMedicine | publisher=Elsevier BV | volume=23 | year=2020 | issn=2589-5370 | doi=10.1016/j.eclinm.2020.100407 | page=100407}}</ref>
|Spain
|65
|61.5 %
|-
|21 April 2020
| Streng A. <ref name="Streng Hartmann Armann Berner pp. 615–627">{{cite journal | last=Streng | first=A. | last2=Hartmann | first2=K. | last3=Armann | first3=J. | last4=Berner | first4=R. | last5=Liese | first5=J. G. | title=COVID-19 bei hospitalisierten Kindern und Jugendlichen | journal=Monatsschrift Kinderheilkunde | publisher=Springer Science and Business Media LLC | volume=168 | issue=7 | date=2020-04-21 | issn=0026-9298 | doi=10.1007/s00112-020-00919-7 | pages=615–627 | language=de}}</ref>
|China
|2143
|39–82%
|-
|10 April 2020
|Fu Leiwen. et al <ref name="Fu Wang Yuan Chen 2020 pp. 656–665">{{cite journal | last=Fu | first=Leiwen | last2=Wang | first2=Bingyi | last3=Yuan | first3=Tanwei | last4=Chen | first4=Xiaoting | last5=Ao | first5=Yunlong | last6=Fitzpatrick | first6=Thomas | last7=Li | first7=Peiyang | last8=Zhou | first8=Yiguo | last9=Lin | first9=Yi-fan | last10=Duan | first10=Qibin | last11=Luo | first11=Ganfeng | last12=Fan | first12=Song | last13=Lu | first13=Yong | last14=Feng | first14=Anping | last15=Zhan | first15=Yuewei | last16=Liang | first16=Bowen | last17=Cai | first17=Weiping | last18=Zhang | first18=Lin | last19=Du | first19=Xiangjun | last20=Li | first20=Linghua | last21=Shu | first21=Yuelong | last22=Zou | first22=Huachun | title=Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: A systematic review and meta-analysis | journal=Journal of Infection | publisher=Elsevier BV | volume=80 | issue=6 | year=2020 | issn=0163-4453 | doi=10.1016/j.jinf.2020.03.041 | pages=656–665}}</ref>
|China
|3600
|73.2 %
|}


=== Age ===


There is no racial predilection to [disease name].
*In another study it was reported that the mean age of the [[population]] was 45 years, and 307 (79%) of 391 cases were adults aged 30–69 years.
*At the time of the first clinical assessment, most cases were mild (102 [26%] of 391) or moderate (254 [65%] of 391), and only 35 (9%) were severe.<ref name="Bi Wu Mei Ye 2020 p.">{{cite journal | last=Bi | first=Qifang | last2=Wu | first2=Yongsheng | last3=Mei | first3=Shujiang | last4=Ye | first4=Chenfei | last5=Zou | first5=Xuan | last6=Zhang | first6=Zhen | last7=Liu | first7=Xiaojian | last8=Wei | first8=Lan | last9=Truelove | first9=Shaun A | last10=Zhang | first10=Tong | last11=Gao | first11=Wei | last12=Cheng | first12=Cong | last13=Tang | first13=Xiujuan | last14=Wu | first14=Xiaoliang | last15=Wu | first15=Yu | last16=Sun | first16=Binbin | last17=Huang | first17=Suli | last18=Sun | first18=Yu | last19=Zhang | first19=Juncen | last20=Ma | first20=Ting | last21=Lessler | first21=Justin | last22=Feng | first22=Tiejian | title=Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study | journal=The Lancet Infectious Diseases | publisher=Elsevier BV | year=2020 | issn=1473-3099 | doi=10.1016/s1473-3099(20)30287-5 | page=}}</ref>


OR
=== Gender ===


[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
*The [[attack rate]] was reported to be more among females than male cases.<ref name="Bi Wu Mei Ye 2020 p.">{{cite journal | last=Bi | first=Qifang | last2=Wu | first2=Yongsheng | last3=Mei | first3=Shujiang | last4=Ye | first4=Chenfei | last5=Zou | first5=Xuan | last6=Zhang | first6=Zhen | last7=Liu | first7=Xiaojian | last8=Wei | first8=Lan | last9=Truelove | first9=Shaun A | last10=Zhang | first10=Tong | last11=Gao | first11=Wei | last12=Cheng | first12=Cong | last13=Tang | first13=Xiujuan | last14=Wu | first14=Xiaoliang | last15=Wu | first15=Yu | last16=Sun | first16=Binbin | last17=Huang | first17=Suli | last18=Sun | first18=Yu | last19=Zhang | first19=Juncen | last20=Ma | first20=Ting | last21=Lessler | first21=Justin | last22=Feng | first22=Tiejian | title=Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study | journal=The Lancet Infectious Diseases | publisher=Elsevier BV | year=2020 | issn=1473-3099 | doi=10.1016/s1473-3099(20)30287-5 | page=}}</ref>


=== Race ===


 
*There is no significant data reporting specific race predilection for the patients developing COVID-19 associated pneumonia.
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 
 
The majority of [disease name] cases are reported in [geographical region].
 
OR
 
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
*The risk factors for COVID-19 associated pneumonia have not been properly established. Multiple studies show following factors to be the key to the progression of disease severity:<ref name="Wang Hu Wang Li p.">{{cite journal | last=Wang | first=Chang‐Zheng | last2=Hu | first2=Shun‐Lin | last3=Wang | first3=Lin | last4=Li | first4=Min | last5=Li | first5=Huan‐Tian | title=Early risk factors of the exacerbation of Coronavirus disease 2019 pneumonia | journal=Journal of Medical Virology | publisher=Wiley | date=2020-05-29 | issn=0146-6615 | doi=10.1002/jmv.26071 | page=}}</ref>
 
**[[Diarrhea]]
OR
**Lymphocyte count  ≤ 1000 microlitre
 
**[[Ferritin]] ≥ 430 ng/ml
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
**[[C-reactive protein|CRP]] ≥ 2.5 mg/dL
 
**[[Consolidation (medicine)|Consolidation]] on CT-scan chest
OR
**Declining [[Neutrophil]] count
 
**[[COPD|COPD history]]
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.


==Screening==
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.


OR
* There is insufficient evidence to recommend routine screening for COVID-19 associated pneumonia.
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].


OR
* Due to the evolution of [[pneumonia]] and high stress [[ventilation]] given as a part of treatment,type L COVID-19 [[pneumonia]] may progress to type H [[pneumonia]] over time.
* The key feature that regulates this transition is the depth of the negative inspiratory intrathoracic pressure that is associated with increased [[tidal volume]] in spontaneous breathing.<ref name="Gattinoni Chiumello Caironi Busana pp. 1099–1102">{{cite journal | last=Gattinoni | first=Luciano | last2=Chiumello | first2=Davide | last3=Caironi | first3=Pietro | last4=Busana | first4=Mattia | last5=Romitti | first5=Federica | last6=Brazzi | first6=Luca | last7=Camporota | first7=Luigi | title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? | journal=Intensive Care Medicine | publisher=Springer Science and Business Media LLC | volume=46 | issue=6 | date=2020-04-14 | issn=0342-4642 | doi=10.1007/s00134-020-06033-2 | pages=1099–1102}}</ref>
* This is based on experimental observation by Barach and Mascheroni. This has been termed as patient self-inflicted lung injury. Over time the increased [[edema]] causes lung weight to increase.
* There is superimposed pressure and dependent [[atelectasis]] that develops over the progression of time.
* When the lung [[edema]] increases massively, the lung's gas volume decreases and then [[Tidal volume|tidal volumes]] that are usually generated for a given pressure also decreases.
* This leads to the development of [[dyspnea]] and worsening of the patient's self-inflicted lung injury.<ref name="Robba Battaglini Ball Patroniti 2020 p=103455">{{cite journal | last=Robba | first=Chiara | last2=Battaglini | first2=Denise | last3=Ball | first3=Lorenzo | last4=Patroniti | first4=Nicolo’ | last5=Loconte | first5=Maurizio | last6=Brunetti | first6=Iole | last7=Vena | first7=Antonio | last8=Giacobbe | first8=Daniele Roberto | last9=Bassetti | first9=Matteo | last10=Rocco | first10=Patricia Rieken Macedo | last11=Pelosi | first11=Paolo | title=Distinct phenotypes require distinct respiratory management strategies in severe COVID-19 | journal=Respiratory Physiology & Neurobiology | publisher=Elsevier BV | volume=279 | year=2020 | issn=1569-9048 | doi=10.1016/j.resp.2020.103455 | page=103455}}</ref>


Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
===Complications===
*Pneumonia due to SARS-CoV-2 can further lead to following complications:
**Worsening [[hypoxemia]]<ref name="Gattinoni Chiumello Caironi Busana pp. 1099–1102">{{cite journal | last=Gattinoni | first=Luciano | last2=Chiumello | first2=Davide | last3=Caironi | first3=Pietro | last4=Busana | first4=Mattia | last5=Romitti | first5=Federica | last6=Brazzi | first6=Luca | last7=Camporota | first7=Luigi | title=COVID-19 pneumonia: different respiratory treatments for different phenotypes? | journal=Intensive Care Medicine | publisher=Springer Science and Business Media LLC | volume=46 | issue=6 | date=2020-04-14 | issn=0342-4642 | doi=10.1007/s00134-020-06033-2 | pages=1099–1102}}</ref>
**[[Acute respiratory distress syndrome|ARDS]]
**[[Barotrauma]] due to mechanical breathing support
**Acute cor-pulmonale
**[[Ventilator associated pneumonia]]


OR
=== Prognosis ===


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
* Generally the progression of L Type pneumonia to the H type co-relates to poor prognosis as it further rapidly progresses to [[Acute respiratory distress syndrome|ARDS]].
* A study reported development of [[Acute respiratory distress syndrome|ARDS]] in 20% patients with a median of eight days after the onset of [[symptoms]].<ref name="Wang Hu Hu Zhu p=1061">{{cite journal | last=Wang | first=Dawei | last2=Hu | first2=Bo | last3=Hu | first3=Chang | last4=Zhu | first4=Fangfang | last5=Liu | first5=Xing | last6=Zhang | first6=Jing | last7=Wang | first7=Binbin | last8=Xiang | first8=Hui | last9=Cheng | first9=Zhenshun | last10=Xiong | first10=Yong | last11=Zhao | first11=Yan | last12=Li | first12=Yirong | last13=Wang | first13=Xinghuan | last14=Peng | first14=Zhiyong | title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China | journal=JAMA | publisher=American Medical Association (AMA) | volume=323 | issue=11 | date=2020-03-17 | issn=0098-7484 | pmid=32031570 | pmc=7042881 | doi=10.1001/jama.2020.1585 | page=1061}}</ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].


OR
* There is no established criteria for the [[diagnosis]] of COVID-19 associated pneumonia.
 
* Initial [[Chest X-ray|chest x-rays]] maybe normal.
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
* CT-scan chest is more sensitive than chest x-ray but there are no set criteria to diagnose COVID-19 associated [[pneumonia]] in COVID-19 patients.
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
There are no established criteria for the diagnosis of [disease name].


===History and Symptoms===
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
OR
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].


* Exposure to SARS-CoV-2 can result into patients exhibiting following signs and symptoms:
** Most common signs and symptoms:
*** Low to high-grade fever (98.6%)
*** Generalized fatigue (69.6%)
*** Non-productive/dry cough (59.4%)
*** [[Myalgias]] (34.8%)
*** [[Dyspnea]] (31.2%)
*** [[Sore throat]]
*** [[Rhinorrhea]]
** Other less common signs and symptoms:
***[[Headache]]
*** [[Abdominal pain]]
*** [[Dizziness]]
*** [[Nausea]]
*** [[Vomiting]]
*** [[Diarrhea]]<ref name="Wang Hu Hu Zhu p=1061">{{cite journal | last=Wang | first=Dawei | last2=Hu | first2=Bo | last3=Hu | first3=Chang | last4=Zhu | first4=Fangfang | last5=Liu | first5=Xing | last6=Zhang | first6=Jing | last7=Wang | first7=Binbin | last8=Xiang | first8=Hui | last9=Cheng | first9=Zhenshun | last10=Xiong | first10=Yong | last11=Zhao | first11=Yan | last12=Li | first12=Yirong | last13=Wang | first13=Xinghuan | last14=Peng | first14=Zhiyong | title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China | journal=JAMA | publisher=American Medical Association (AMA) | volume=323 | issue=11 | date=2020-03-17 | issn=0098-7484 | pmid=32031570 | pmc=7042881 | doi=10.1001/jama.2020.1585 | page=1061}}</ref>
{| class="wikitable"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Mild Illness }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Moderate Pneumonia }}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Severe Pneumonia }}
|-
|
* Mild fever
* [[Cough]] (dry)
* [[Sore throat]]
* [[Nasal congestion]]
* [[Malaise]]
* [[Headache]]
* Muscle pain
|
* [[Cough]] is the most predominant symptom.
|
* [[Respiratory distress]]
|-
|
* [[Anosmia]]
* [[Diarrhea]]
* [[Vomiting]] (can be present in some patients)
|
* [[Dyspnea]] or [[tachypnea]] (children)
|
* [[Tachypnea]] (>30 breaths/min)
|-
|
* [[Dyspnea]] is not usually observed in mild cases.
|
|
* [[Hypoxia]] (SpO2 < 90% on room air)
|}
===Physical Examination===
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
* Common physical examination findings include the following:
** [[Fever]] (most common)
** [[Respiratory rate]] >24 breaths/minute (almost all patients)
**[[Pulse rate]] >100  beats/min.
** Audible [[crackles]] (on chest examination)
** Signs of [[Consolidation (medicine)|consolidation]] can be present in as early signs of [[pneumonia]] in COVID-19 patients such as:
***Decreased or [[Breath sounds|bronchial breath sounds]]
***Dullness to [[percussion]]
***[[Tactile fremitus]]
***[[Egophony]]  


===Laboratory Findings===
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
*Common laboratory findings among hospitalized patients with COVID-19 include:
 
**[[Lymphocytopenia|Lymphopenia]] (lymphocyte count, 0.8 × 109/L [interquartile range {IQR}, 0.6-1.1])
OR
**Elevated aminotransaminase levels
 
**Elevated [[lactate dehydrogenase]] levels
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
**Elevated  [[ferritin]]
 
**Elevated [[CRP]]
OR
**Elevated [[Erythrocyte sedimentation rate|ESR]]
 
**Elevated [[procalcitonin]] levels in those requiring ICU care
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].


===Electrocardiogram===
===Electrocardiogram===
There are no ECG findings associated with [disease name].


OR
* There are no specific ECG findings associated with COVID-19 associated [[pneumonia]].
 
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===X-ray===
There are no x-ray findings associated with [disease name].


OR
* Chest radiograph may show [[bilateral]], almost symmetrical areas of peripheral [[Consolidation (medicine)|consolidation]] with perihilar infiltrates. In an endemic area, these appearances are highly suggestive of infection with COVID-19.
*The primary findings of COVID-19 are those of [[Atypical pneumonia|atypical]] or [[organizing pneumonia]].<ref name="Rodrigues Hare Edey Devaraj 2020 pp. 323–325">{{cite journal | last=Rodrigues | first=J.C.L. | last2=Hare | first2=S.S. | last3=Edey | first3=A. | last4=Devaraj | first4=A. | last5=Jacob | first5=J. | last6=Johnstone | first6=A. | last7=McStay | first7=R. | last8=Nair | first8=A. | last9=Robinson | first9=G. | title=An update on COVID-19 for the radiologist - A British society of Thoracic Imaging statement | journal=Clinical Radiology | publisher=Elsevier BV | volume=75 | issue=5 | year=2020 | issn=0009-9260 | doi=10.1016/j.crad.2020.03.003 | pages=323–325}}</ref>
* Almost 18 % of the patients can have normal chest x-ray findings early in the disease course but only 3% in severe disease.<ref name="Guan Ni Hu Liang pp. 1708–1720">{{cite journal | last=Guan | first=Wei-jie | last2=Ni | first2=Zheng-yi | last3=Hu | first3=Yu | last4=Liang | first4=Wen-hua | last5=Ou | first5=Chun-quan | last6=He | first6=Jian-xing | last7=Liu | first7=Lei | last8=Shan | first8=Hong | last9=Lei | first9=Chun-liang | last10=Hui | first10=David S.C. | last11=Du | first11=Bin | last12=Li | first12=Lan-juan | last13=Zeng | first13=Guang | last14=Yuen | first14=Kwok-Yung | last15=Chen | first15=Ru-chong | last16=Tang | first16=Chun-li | last17=Wang | first17=Tao | last18=Chen | first18=Ping-yan | last19=Xiang | first19=Jie | last20=Li | first20=Shi-yue | last21=Wang | first21=Jin-lin | last22=Liang | first22=Zi-jing | last23=Peng | first23=Yi-xiang | last24=Wei | first24=Li | last25=Liu | first25=Yong | last26=Hu | first26=Ya-hua | last27=Peng | first27=Peng | last28=Wang | first28=Jian-ming | last29=Liu | first29=Ji-yang | last30=Chen | first30=Zhong | last31=Li | first31=Gang | last32=Zheng | first32=Zhi-jian | last33=Qiu | first33=Shao-qin | last34=Luo | first34=Jie | last35=Ye | first35=Chang-jiang | last36=Zhu | first36=Shao-yong | last37=Zhong | first37=Nan-shan | title=Clinical Characteristics of Coronavirus Disease 2019 in China | journal=New England Journal of Medicine | publisher=Massachusetts Medical Society | volume=382 | issue=18 | date=2020-04-30 | issn=0028-4793 | doi=10.1056/nejmoa2002032 | pages=1708–1720}}</ref>
* Bilateral and/or multilobar involvement is common.
* CXR typically shows patchy or diffuse asymmetric airspace opacities which is also seen in other [[coronaviruses]] cases.<ref name="Chen Yang Yang Wang 2020 pp. 764–766">{{cite journal | last=Chen | first=Simiao | last2=Yang | first2=Juntao | last3=Yang | first3=Weizhong | last4=Wang | first4=Chen | last5=Bärnighausen | first5=Till | title=COVID-19 control in China during mass population movements at New Year | journal=The Lancet | publisher=Elsevier BV | volume=395 | issue=10226 | year=2020 | issn=0140-6736 | doi=10.1016/s0140-6736(20)30421-9 | pages=764–766}}</ref>


An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
[[File:Covid-19-pneumonia-42.jpeg|300px|thumb|none|Chest radiograph on admission demonstrates bilateral, almost symmetrical areas of peripheral consolidation with perihilar infiltrates and an indistinct left heart border. In an endemic area, appearances are highly suggestive of COVID-19. [https://radiopaedia.org/cases/covid-19-pneumonia-42?lang=us Source: Dr. Roma Patel]]]
 
OR
 
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].


OR
* There are no specific echocardiography/ultrasound findings associated with COVID-19 associated pneumonia.
 
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
*CT-scan chest findings in a patient with COVID-19 pneumonia may show following abnormalities:<ref name="Bai Hsieh Xiong Halsey p=200823">{{cite journal | last=Bai | first=Harrison X. | last2=Hsieh | first2=Ben | last3=Xiong | first3=Zeng | last4=Halsey | first4=Kasey | last5=Choi | first5=Ji Whae | last6=Tran | first6=Thi My Linh | last7=Pan | first7=Ian | last8=Shi | first8=Lin-Bo | last9=Wang | first9=Dong-Cui | last10=Mei | first10=Ji | last11=Jiang | first11=Xiao-Long | last12=Zeng | first12=Qiu-Hua | last13=Egglin | first13=Thomas K. | last14=Hu | first14=Ping-Feng | last15=Agarwal | first15=Saurabh | last16=Xie | first16=Fangfang | last17=Li | first17=Sha | last18=Healey | first18=Terrance | last19=Atalay | first19=Michael K. | last20=Liao | first20=Wei-Hua | title=Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT | journal=Radiology | publisher=Radiological Society of North America (RSNA) | date=2020-03-10 | issn=0033-8419 | doi=10.1148/radiol.2020200823 | page=200823}}</ref>
 
**Ground-glass opacities
OR
** Crazy paving appearance
 
**Air space [[Consolidation (medicine)|consolidation]]
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
**Bronchovascular thickening in the lesion
 
**Traction [[bronchiectasis]]
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===MRI===
There are no MRI findings associated with [disease name].
 
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
 
OR


[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
[[File:Covid-19-pneumonia-89.png|thumb|300px|none|Key findings: 1) two small areas of ground-glass opacity (GGO) on day 3 2) extensive crazy-paving pattern (red arrowhead) and consolidations (blue arrowheads) and bilateral pleural effusions (red measurement) on day 15. [https://radiopaedia.org/cases/covid-19-pneumonia-89?lang=us Source: Dr. Joachim Feger]]]


===Other Diagnostic Studies===
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
OR


[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
====Bronchoalveolar Lavage====


OR
* [[Bronchoalveolar lavage]] may not be useful in diagnosing COVID-19 pneumonia, however various case reports suggest a collection of [[Bronchoalveolar lavage|BAL]] fluid when consecutive nasopharyngeal swabs are negative to confirm or exclude the diagnosis of COVID-19-associated pneumonia.<ref name="Gualano Musso Mosti Mencarini 2020 pp. 174–176">{{cite journal | last=Gualano | first=Gina | last2=Musso | first2=Maria | last3=Mosti | first3=Silvia | last4=Mencarini | first4=Paola | last5=Mastrobattista | first5=Annelisa | last6=Pareo | first6=Carlo | last7=Zaccarelli | first7=Mauro | last8=Migliorisi | first8=Paolo | last9=Vittozzi | first9=Pietro | last10=Zumla | first10=Alimudin | last11=Ippolito | first11=Giuseppe | last12=Palmieri | first12=Fabrizio | title=Usefulness of bronchoalveolar lavage in the management of patients presenting with lung infiltrates and suspect COVID-19-associated pneumonia: A case report | journal=International Journal of Infectious Diseases | publisher=Elsevier BV | volume=97 | year=2020 | issn=1201-9712 | doi=10.1016/j.ijid.2020.05.027 | pages=174–176}}</ref>
 
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].


OR
* The mainstay of treatment for COVID-19 associated pneumonia is supportive care and mechanical respiratory support.
* For suspected [[bacterial]] co-infection which may depict as elevated [[WBC]], positive [[sputum culture]], positive urinary antigen and atypical chest imaging, administer empiric coverage for [[Community-acquired pneumonia|community-acquired]] or [[Hospital-acquired pneumonia|health-care associated pneumonia]].
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
* As there have been 3 distinct [[phenotypes]] of COVID-19 pneumonia, so there have been different treatment modalities for each of them.


OR
* The first step is to reverse [[hypoxemia]] which can be done through increase in [[FiO2|FiO<sub>2</sub>]]. This is well tolerated in patients with Type L pneumonia.
* For L Type with dyspnea, following different non-invasive options are available:
**High flow nasal cannula (HFNC)
**[[Positive airway pressure|Continuous positive airway pressure]] (CPAP)
**Non-invasive ventilation (NIV)
*Esophageal manometry pressure is measured to prevent swings of [[Central venous pressure|central venous pressure.]]
*P0.1 and P<sub>occlusion</sub> should be measured in intubated patient.
*[[Ventilation|Mechanical Ventilation]] should be instituted at the appropriate time.


[Therapy] is recommended among all patients who develop [disease name].
[[File:Corel-draw-pneumonia-mechanical vent-temp.jpg|800px|center]]
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
 
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
 
OR
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].


===Primary Prevention===
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
*The best way to prevent being infected by COVID-19 is to avoid being exposed to this [[virus]] by adopting the following practices for [[infection]] control:
 
**Often wash hands with [[soap]] and [[water]] for at least 20 seconds.
OR
**Use an [[Hand sanitizer|alcohol-based hand sanitizer]] containing at least 60% [[alcohol]] in case [[soap]] and [[water]] are not available.
 
**Avoid touching the [[Eye|eyes]], [[nose]], and [[mouth]] without washing hands.
There are no available vaccines against [disease name].
**Avoid being in close contact with people sick with COVID-19 infection.
 
**Stay home while being [[symptomatic]] to prevent spread to others.
OR
**Cover mouth while [[cough|coughing]] or [[sneeze|sneezing]] with a tissue paper, and then throw the tissue in the trash.
 
**Clean and [[Disinfection|disinfect]] the objects and surfaces which are touched frequently.
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
*There is currently no [[vaccine]] available to prevent COVID-19.
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].


===Secondary Prevention===
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
*The secondary prevention measures of Coronavirus disease 2019 (COVID-19) constitute protective measures to make sure that an infected individual does not transfer the disease to others by maintaining self-isolation at home or designated [[quarantine]] facilities.
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Up-To-Date]]


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Latest revision as of 18:56, 29 July 2020

Main article: COVID-19

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For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
For COVID-19 patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords:2019 novel coronavirus disease, COVID19, Wuhan virus, L type COVID pneumonia, H type Pneumonia

Overview

In December 2019, a novel coronavirus was detected in pneumonia patients in the Chinese city of Wuhan. The novel coronavirus was later named as 2019-nCoV. Since it was identified, pneumonia appears to be the most frequent manifestation of infection. Despite mimicking the symptoms and criteria of Berlin's definition of ARDS, COVID-19 pneumonia is a distinct disease with features including severe hypoxemia often associated with the normal or near-normal respiratory system compliance.

Historical Perspective

  • In December 2019, there were case reports of a cluster of acute respiratory illness in the Wuhan, Hubei Province, China.
  • In January 2020, novel coronavirus was identified in the samples of bronchoalveolar lavage fluid from a patient in Wuhan.[1]
  • Later this has been confirmed as the cause of novel corona virus-infected pneumonia.
  • The first cases were reported by Huang et al in which most of the patients had a history of exposure to the seafood wholesale market.
  • There have been no effective therapies or vaccines available for NCIP as of yet.
  • In May 2020, it was postulated that there is also a third distinctive type. This phenotype usually mimics the patchy ARDS phenotype.

Classification

  • There is no established system for the classification of coronavirus infected pneumonia. Based on the detailed observation of case reports and case series, it has been found that COVID-19 patients differ in their presentation in the emergency department based upon the following three factors:
  1. The severity of infection, host immune response, preserved physiological reserve, and associated comorbidities.
  2. Response of patient to the hypoxemia in terms of ventilator
  3. the time between the presentation of patient to the emergency department and the onset of the disease.
  • Based on these three factors, NCIP has been divided COVID-19 associated pneumonia into the following two different phenotypes[2] :
COVID‑19 pneumonia, Type L COVID‑19 pneumonia, Type H
Low elastance High elastance
Low ventilation to perfusion ratio High Left to right shunt
Low lung weight High lung weight
Low lung recruitability. High lung recruitability
  • The H type pattern has been reported to present in 20-30 % patients in one case series. It usually fits the criteria of severe ARDS or progresses rapidly towards ARDS.[2]
  • In May 2020, it was postulated that there is also a third distinctive type. This phenotype usually mimics the patchy ARDS phenotype.

Pathophysiology

The exact pathogenesis behind COVID-19 associated pneumonia is not yet fully understood.

Differentiating COVID-19-associated pneumonia from other Diseases

  • For further information on COVID-19-associated pneumonia click here.
  • To view the COVID-19 differential diagnosis click here.

Epidemiology and Demographics

Incidence/Prevalence of COVID-19 Associated Pneumonia
Date Published Author Country Total Number Of Patients Incidence/Prevalence
01 June,2020 San-Juan Rafael. [6] Spain 65 61.5 %
21 April 2020 Streng A. [7] China 2143 39–82%
10 April 2020 Fu Leiwen. et al [8] China 3600 73.2 %

Age

  • In another study it was reported that the mean age of the population was 45 years, and 307 (79%) of 391 cases were adults aged 30–69 years.
  • At the time of the first clinical assessment, most cases were mild (102 [26%] of 391) or moderate (254 [65%] of 391), and only 35 (9%) were severe.[9]

Gender

  • The attack rate was reported to be more among females than male cases.[9]

Race

  • There is no significant data reporting specific race predilection for the patients developing COVID-19 associated pneumonia.

Risk Factors

  • The risk factors for COVID-19 associated pneumonia have not been properly established. Multiple studies show following factors to be the key to the progression of disease severity:[10]

Screening

  • There is insufficient evidence to recommend routine screening for COVID-19 associated pneumonia.

Natural History, Complications, and Prognosis

  • Due to the evolution of pneumonia and high stress ventilation given as a part of treatment,type L COVID-19 pneumonia may progress to type H pneumonia over time.
  • The key feature that regulates this transition is the depth of the negative inspiratory intrathoracic pressure that is associated with increased tidal volume in spontaneous breathing.[11]
  • This is based on experimental observation by Barach and Mascheroni. This has been termed as patient self-inflicted lung injury. Over time the increased edema causes lung weight to increase.
  • There is superimposed pressure and dependent atelectasis that develops over the progression of time.
  • When the lung edema increases massively, the lung's gas volume decreases and then tidal volumes that are usually generated for a given pressure also decreases.
  • This leads to the development of dyspnea and worsening of the patient's self-inflicted lung injury.[12]

Complications

Prognosis

  • Generally the progression of L Type pneumonia to the H type co-relates to poor prognosis as it further rapidly progresses to ARDS.
  • A study reported development of ARDS in 20% patients with a median of eight days after the onset of symptoms.[1]

Diagnosis

Diagnostic Study of Choice

  • There is no established criteria for the diagnosis of COVID-19 associated pneumonia.
  • Initial chest x-rays maybe normal.
  • CT-scan chest is more sensitive than chest x-ray but there are no set criteria to diagnose COVID-19 associated pneumonia in COVID-19 patients.

History and Symptoms

Mild Illness Moderate Pneumonia Severe Pneumonia
  • Cough is the most predominant symptom.
  • Dyspnea is not usually observed in mild cases.

Physical Examination

Laboratory Findings

  • Common laboratory findings among hospitalized patients with COVID-19 include:

Electrocardiogram

  • There are no specific ECG findings associated with COVID-19 associated pneumonia.

X-ray

  • Chest radiograph may show bilateral, almost symmetrical areas of peripheral consolidation with perihilar infiltrates. In an endemic area, these appearances are highly suggestive of infection with COVID-19.
  • The primary findings of COVID-19 are those of atypical or organizing pneumonia.[13]
  • Almost 18 % of the patients can have normal chest x-ray findings early in the disease course but only 3% in severe disease.[14]
  • Bilateral and/or multilobar involvement is common.
  • CXR typically shows patchy or diffuse asymmetric airspace opacities which is also seen in other coronaviruses cases.[15]
Chest radiograph on admission demonstrates bilateral, almost symmetrical areas of peripheral consolidation with perihilar infiltrates and an indistinct left heart border. In an endemic area, appearances are highly suggestive of COVID-19. Source: Dr. Roma Patel

Echocardiography or Ultrasound

  • There are no specific echocardiography/ultrasound findings associated with COVID-19 associated pneumonia.

CT scan

  • CT-scan chest findings in a patient with COVID-19 pneumonia may show following abnormalities:[16]
    • Ground-glass opacities
    • Crazy paving appearance
    • Air space consolidation
    • Bronchovascular thickening in the lesion
    • Traction bronchiectasis
Key findings: 1) two small areas of ground-glass opacity (GGO) on day 3 2) extensive crazy-paving pattern (red arrowhead) and consolidations (blue arrowheads) and bilateral pleural effusions (red measurement) on day 15. Source: Dr. Joachim Feger

Other Diagnostic Studies

Bronchoalveolar Lavage

  • Bronchoalveolar lavage may not be useful in diagnosing COVID-19 pneumonia, however various case reports suggest a collection of BAL fluid when consecutive nasopharyngeal swabs are negative to confirm or exclude the diagnosis of COVID-19-associated pneumonia.[17]

Treatment

Medical Therapy

  • The mainstay of treatment for COVID-19 associated pneumonia is supportive care and mechanical respiratory support.
  • For suspected bacterial co-infection which may depict as elevated WBC, positive sputum culture, positive urinary antigen and atypical chest imaging, administer empiric coverage for community-acquired or health-care associated pneumonia.
  • As there have been 3 distinct phenotypes of COVID-19 pneumonia, so there have been different treatment modalities for each of them.
  • The first step is to reverse hypoxemia which can be done through increase in FiO2. This is well tolerated in patients with Type L pneumonia.
  • For L Type with dyspnea, following different non-invasive options are available:
  • Esophageal manometry pressure is measured to prevent swings of central venous pressure.
  • P0.1 and Pocclusion should be measured in intubated patient.
  • Mechanical Ventilation should be instituted at the appropriate time.

Primary Prevention

  • The best way to prevent being infected by COVID-19 is to avoid being exposed to this virus by adopting the following practices for infection control:
    • Often wash hands with soap and water for at least 20 seconds.
    • Use an alcohol-based hand sanitizer containing at least 60% alcohol in case soap and water are not available.
    • Avoid touching the eyes, nose, and mouth without washing hands.
    • Avoid being in close contact with people sick with COVID-19 infection.
    • Stay home while being symptomatic to prevent spread to others.
    • Cover mouth while coughing or sneezing with a tissue paper, and then throw the tissue in the trash.
    • Clean and disinfect the objects and surfaces which are touched frequently.
  • There is currently no vaccine available to prevent COVID-19.

Secondary Prevention

  • The secondary prevention measures of Coronavirus disease 2019 (COVID-19) constitute protective measures to make sure that an infected individual does not transfer the disease to others by maintaining self-isolation at home or designated quarantine facilities.

References

  1. ↑ 1.0 1.1 1.2 Wang, Dawei; Hu, Bo; Hu, Chang; Zhu, Fangfang; Liu, Xing; Zhang, Jing; Wang, Binbin; Xiang, Hui; Cheng, Zhenshun; Xiong, Yong; Zhao, Yan; Li, Yirong; Wang, Xinghuan; Peng, Zhiyong (2020-03-17). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China". JAMA. American Medical Association (AMA). 323 (11): 1061. doi:10.1001/jama.2020.1585. ISSN 0098-7484.
  2. ↑ 2.0 2.1 "COVID-19-associated pneumonia". wikidoc. 2020-03-17. Retrieved 2020-07-13.
  3. ↑ Yuki, Koichi; Fujiogi, Miho; Koutsogiannaki, Sophia (2020). "COVID-19 pathophysiology: A review". Clinical Immunology. Elsevier BV. 215: 108427. doi:10.1016/j.clim.2020.108427. ISSN 1521-6616.
  4. ↑ Glowacka, I.; Bertram, S.; Muller, M. A.; Allen, P.; Soilleux, E.; Pfefferle, S.; Steffen, I.; Tsegaye, T. S.; He, Y.; Gnirss, K.; Niemeyer, D.; Schneider, H.; Drosten, C.; Pohlmann, S. (2011-02-16). "Evidence that TMPRSS2 Activates the Severe Acute Respiratory Syndrome Coronavirus Spike Protein for Membrane Fusion and Reduces Viral Control by the Humoral Immune Response". Journal of Virology. American Society for Microbiology. 85 (9): 4122–4134. doi:10.1128/jvi.02232-10. ISSN 0022-538X.
  5. ↑ Costela-Ruiz, Víctor J.; Illescas-Montes, Rebeca; Puerta-Puerta, Jose M.; Ruiz, Concepción; Melguizo-Rodríguez, Lucia (2020). "SARS-CoV-2 infection: The role of cytokines in COVID-19 disease". Cytokine & Growth Factor Reviews. Elsevier BV. doi:10.1016/j.cytogfr.2020.06.001. ISSN 1359-6101.
  6. ↑ San-Juan, Rafael; Barbero, Patricia; Fernández-Ruiz, Mario; López-Medrano, Francisco; Lizasoáin, Manuel; Hernández-Jiménez, Pilar; Silva, José Tiago; Ruiz-Ruigómez, María; Corbella, Laura; Rodríguez-Goncer, Isabel; Folgueira, María Dolores; Lalueza, Antonio; Batllori, Emma; Mejía, Inma; Forcén, Laura; Lumbreras, Carlos; García-Burguillo, Antonio; Galindo, Alberto; Aguado, José María (2020). "Incidence and clinical profiles of COVID-19 pneumonia in pregnant women: A single-centre cohort study from Spain". EClinicalMedicine. Elsevier BV. 23: 100407. doi:10.1016/j.eclinm.2020.100407. ISSN 2589-5370.
  7. ↑ Streng, A.; Hartmann, K.; Armann, J.; Berner, R.; Liese, J. G. (2020-04-21). "COVID-19 bei hospitalisierten Kindern und Jugendlichen". Monatsschrift Kinderheilkunde (in Deutsch). Springer Science and Business Media LLC. 168 (7): 615–627. doi:10.1007/s00112-020-00919-7. ISSN 0026-9298.
  8. ↑ Fu, Leiwen; Wang, Bingyi; Yuan, Tanwei; Chen, Xiaoting; Ao, Yunlong; Fitzpatrick, Thomas; Li, Peiyang; Zhou, Yiguo; Lin, Yi-fan; Duan, Qibin; Luo, Ganfeng; Fan, Song; Lu, Yong; Feng, Anping; Zhan, Yuewei; Liang, Bowen; Cai, Weiping; Zhang, Lin; Du, Xiangjun; Li, Linghua; Shu, Yuelong; Zou, Huachun (2020). "Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: A systematic review and meta-analysis". Journal of Infection. Elsevier BV. 80 (6): 656–665. doi:10.1016/j.jinf.2020.03.041. ISSN 0163-4453.
  9. ↑ 9.0 9.1 Bi, Qifang; Wu, Yongsheng; Mei, Shujiang; Ye, Chenfei; Zou, Xuan; Zhang, Zhen; Liu, Xiaojian; Wei, Lan; Truelove, Shaun A; Zhang, Tong; Gao, Wei; Cheng, Cong; Tang, Xiujuan; Wu, Xiaoliang; Wu, Yu; Sun, Binbin; Huang, Suli; Sun, Yu; Zhang, Juncen; Ma, Ting; Lessler, Justin; Feng, Tiejian (2020). "Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study". The Lancet Infectious Diseases. Elsevier BV. doi:10.1016/s1473-3099(20)30287-5. ISSN 1473-3099.
  10. ↑ Wang, Chang‐Zheng; Hu, Shun‐Lin; Wang, Lin; Li, Min; Li, Huan‐Tian (2020-05-29). "Early risk factors of the exacerbation of Coronavirus disease 2019 pneumonia". Journal of Medical Virology. Wiley. doi:10.1002/jmv.26071. ISSN 0146-6615.
  11. ↑ 11.0 11.1 Gattinoni, Luciano; Chiumello, Davide; Caironi, Pietro; Busana, Mattia; Romitti, Federica; Brazzi, Luca; Camporota, Luigi (2020-04-14). "COVID-19 pneumonia: different respiratory treatments for different phenotypes?". Intensive Care Medicine. Springer Science and Business Media LLC. 46 (6): 1099–1102. doi:10.1007/s00134-020-06033-2. ISSN 0342-4642.
  12. ↑ Robba, Chiara; Battaglini, Denise; Ball, Lorenzo; Patroniti, Nicolo’; Loconte, Maurizio; Brunetti, Iole; Vena, Antonio; Giacobbe, Daniele Roberto; Bassetti, Matteo; Rocco, Patricia Rieken Macedo; Pelosi, Paolo (2020). "Distinct phenotypes require distinct respiratory management strategies in severe COVID-19". Respiratory Physiology & Neurobiology. Elsevier BV. 279: 103455. doi:10.1016/j.resp.2020.103455. ISSN 1569-9048.
  13. ↑ Rodrigues, J.C.L.; Hare, S.S.; Edey, A.; Devaraj, A.; Jacob, J.; Johnstone, A.; McStay, R.; Nair, A.; Robinson, G. (2020). "An update on COVID-19 for the radiologist - A British society of Thoracic Imaging statement". Clinical Radiology. Elsevier BV. 75 (5): 323–325. doi:10.1016/j.crad.2020.03.003. ISSN 0009-9260.
  14. ↑ Guan, Wei-jie; Ni, Zheng-yi; Hu, Yu; Liang, Wen-hua; Ou, Chun-quan; He, Jian-xing; Liu, Lei; Shan, Hong; Lei, Chun-liang; Hui, David S.C.; Du, Bin; Li, Lan-juan; Zeng, Guang; Yuen, Kwok-Yung; Chen, Ru-chong; Tang, Chun-li; Wang, Tao; Chen, Ping-yan; Xiang, Jie; Li, Shi-yue; Wang, Jin-lin; Liang, Zi-jing; Peng, Yi-xiang; Wei, Li; Liu, Yong; Hu, Ya-hua; Peng, Peng; Wang, Jian-ming; Liu, Ji-yang; Chen, Zhong; Li, Gang; Zheng, Zhi-jian; Qiu, Shao-qin; Luo, Jie; Ye, Chang-jiang; Zhu, Shao-yong; Zhong, Nan-shan (2020-04-30). "Clinical Characteristics of Coronavirus Disease 2019 in China". New England Journal of Medicine. Massachusetts Medical Society. 382 (18): 1708–1720. doi:10.1056/nejmoa2002032. ISSN 0028-4793.
  15. ↑ Chen, Simiao; Yang, Juntao; Yang, Weizhong; Wang, Chen; Bärnighausen, Till (2020). "COVID-19 control in China during mass population movements at New Year". The Lancet. Elsevier BV. 395 (10226): 764–766. doi:10.1016/s0140-6736(20)30421-9. ISSN 0140-6736.
  16. ↑ Bai, Harrison X.; Hsieh, Ben; Xiong, Zeng; Halsey, Kasey; Choi, Ji Whae; Tran, Thi My Linh; Pan, Ian; Shi, Lin-Bo; Wang, Dong-Cui; Mei, Ji; Jiang, Xiao-Long; Zeng, Qiu-Hua; Egglin, Thomas K.; Hu, Ping-Feng; Agarwal, Saurabh; Xie, Fangfang; Li, Sha; Healey, Terrance; Atalay, Michael K.; Liao, Wei-Hua (2020-03-10). "Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT". Radiology. Radiological Society of North America (RSNA): 200823. doi:10.1148/radiol.2020200823. ISSN 0033-8419.
  17. ↑ Gualano, Gina; Musso, Maria; Mosti, Silvia; Mencarini, Paola; Mastrobattista, Annelisa; Pareo, Carlo; Zaccarelli, Mauro; Migliorisi, Paolo; Vittozzi, Pietro; Zumla, Alimudin; Ippolito, Giuseppe; Palmieri, Fabrizio (2020). "Usefulness of bronchoalveolar lavage in the management of patients presenting with lung infiltrates and suspect COVID-19-associated pneumonia: A case report". International Journal of Infectious Diseases. Elsevier BV. 97: 174–176. doi:10.1016/j.ijid.2020.05.027. ISSN 1201-9712.


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