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Evidence Check - Symptoms, diagnosis and treatment

Asymptomatic, disease progression, ambulance, drugs, community, hospitalisation, recovery, palliative care, death.

Neonates and COVID-19 evidence check

Added: 22 Apr 2020
Updated: 28 Apr 2020

The Maternity Community of Practice requires some urgent information on the risk of newborn babies developing COVID-19.
  • Neonatal infection has been documented
  • Neonates may become infected via droplet transmission from virus carriers
  • The incubation period for COVID-19 is 1-14 days. There is no evidence to suggest this is different in neonates
  • The clinical symptoms from neonates with or at risk of COVID-19 are mild. Symptoms include shortness of breath, fever and lethargy.
  • No cases of vertical transmission have been confirmed but the possibility has not been excluded
  • COVID-19 has not been detected in cord blood, amniotic fluid, or placental tissue
  • Viraemia rates appear to be low (around 1% of positive cases), suggesting placental seeding and vertical transmission are unlikely

Inpatient management of COVID-19 evidence check

Added: 20 Apr 2020
Updated: 28 Apr 2020

What guidelines are available for the inpatient management of COVID-19?
  • Guidance is published by organisations including the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), the National Institutes of health, the Australian National COVID-19 Clinical Evidence Taskforce, and in peer reviewed journals.
  • Investigations include, chest x-ray, ultrasound, and if indicated computed tomography (CT) and/or Electrocardiogram (ECG), laboratory testing comprising a complete blood count (CBC) including liver and kidney function tests. Measurements of inflammatory markers such as C-reactive protein (CRP), D-dimer, and ferritin, may have prognostic value.
  • Patients’ vital signs and oxygen saturation should be monitored and supportive treatment given. Some guidelines advise repeat blood tests on days three, five and seven following admission.
  • Patients should be given effective oxygen therapy, one publication suggests monitoring patients on oxygen therapy 30 minutes initially, then every two or six hours depending on results. Currently, there is no evidence to support the effectiveness of existing antiviral drugs.
  • Some individual hospitals have made their treatment protocols publicly available.

Spirometry and transmission risk evidence check

Added: 23 Apr 2020

Is there evidence that spirometry is an aerosol generating procedure and what risk does it carry?
  • Peak organisations such as the World Health Organisation (WHO) and the National Health Service (NHS) do not list spirometry as an aerosol generating procedure.
  • There is very little and low level evidence. One non-human experimental article suggests that a significant transfer of aerosolised organisms does not occur during routine pulmonary function testing
  • as long as an interval of 5 minutes or more is allowed between tests.
  • A systematic review included spirometry in its search terms for aerosol generating procedures but did not generate any studies.
  • Two case reports have presented circumstantial evidence of the transmission of infection by respiratory function testing equipment. Recent Chinese expert consensus outline risks of pulmonary function testing and suggest prevention and control strategies to prevent nosocomial infection during COVID-19.

Non-invasive ventilation and inspiratory muscle training for spinal cord injury patients evidence check

Added: 22 Apr 2020

What evidence is available regarding community or home-based non-invasive ventilation (NIV) for people with spinal cord injuries during COVID-19?
What evidence is available regarding inspiratory muscle training (IMT) for people with spinal cord injuries during COVID-19: What is the aerosolisation risk associated with IMT?
  • There are no clinical practice guidelines, systematic reviews, or research papers on community or home-based NIV during COVID-19 for people with spinal cord injuries.

Palliative care and COVID-19 evidence check

Added: 12 Apr 2020

What evidence is available on the organisation of palliative care services during COVID-19 (or previous pandemics)?
  • Published guidance varies in the use of stepped approaches to palliative care as demand increases in the course of the COVID-19 outbreak
  • Guidelines from Switzerland emphasise the importance of providing access to palliative care, clarifying goals in advance, interdisciplinary team decisions and psychosocial and spiritual needs
  • A rapid review of previous pandemics and insights from experts in the field both acknowledge the need to respond rapidly and flexibly to changing circumstances, to train non-specialists in palliative care, deploy volunteers, and use technology to support communication with patients and carers
  • A case report of a staged model for providing palliative care outlines what comprises ‘conventional’, ‘contingency’ and ‘crisis’ models of care
  • A narrative article outlines a pandemic plan with four key themes: ‘stuff’ (stockpile medications for common symptoms), staff (identify all clinicians with palliative care expertise), space (identify wards that could accommodate large numbers of people) and systems (create a triage system).

Continuous Positive Airway Pressure (CPAP) machines evidence check

Added: 10 Apr 2020

What is the evidence that continuous positive airway pressure (CPAP) and/or Bilevel Positive Airway Pressure (BiPAP) are aerosol generating?
What is the current advice regarding for use of CPAP as a substitute for ventilators during the COVID-19 pandemic?
  • There is limited evidence on the topic of CPAP and/or BiPAP as aerosol generating procedures. Some publications describe CPAP and BiPAP as potential aerosol-generating procedures involved in nosocomial virus transmission. A systematic review found non-significant results for transmission for CPAP
  • Healthcare authorities in Australia (TGA) and the US (FDA) believe that modifications to these modes of therapy would not create undue risks to treat patients with COVID-19 with respiratory insufficiency, provided that appropriate mitigations are in place to minimise aerosolisation
  • The use of CPAP may forestall the need for or provide a bridge to intubation, and some guidance states that CPAP is the preferred form of non-invasive ventilatory support
  • Regulators and medical device companies recommend healthcare professionals utilise PPE when using CPAP on COVID-19 patients due to the potential risk of transmission
  • There is limited advice on the use of CPAP in community settings during COVID-19, and no studies on bubble CPAP.

Prone position for COVID-19 patients evidence check

Added: 28 Mar 2020

What is the evidence for the prone position in patients with COVID-19?
  • The World Health Organisation guidelines recommend prone ventilation for 12–16 hours per day for adult patients with severe acute respiratory infection with COVID-19
  • A study of 12 people in Wuhan, China, with COVID-19-related acute respiratory distress syndrome has suggested that alternating supine and prone positioning was associated with increased lung recruitability
  • Commentaries from the Lancet, JAMA insights and Anaesthesiology suggest the use of the prone position for COVID-19 patients

Laparoscopy during COVID-19 evidence check

Added: 25 Mar 2020

Should laparoscopy be avoided and classed as an aerosol procedure during COVID-19?
  • Surgical smoke during laparoscopy contains bio-aerosols which poses high risk to operating staff
  • Operating staff should be cautious, aware, wear protective gear and take precautionary measures if conducting emergency laparoscopic surgery

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.

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