COVID- 19 Treatment guideline in Tanzania
March,2021
Posted by ULY CLINIC
24 Machi 2021, 15:04:18
The guidance in this document is based on proper case management aspects intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen frontline clinical management and the public health response.
DISCLAIMER. THIS GUIDELINE IS THE POPERTY OF MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN
5. RESPIRATORY MANAGEMENT FOR COVID-19 PATIENT
The cornerstone for the management of the hypoxaemia COVID-19 patient is the application of oxygen therapy via a variety of delivery methods and target SpO2 ≥90% in non-pregnant adults, titrating to reach targets by means of a nasal cannula, simple face mask or face mask with reservoir bag.
Give supplemental oxygen therapy immediately to patients with low oxygen saturation
Oxygen therapy is likely to be the single most effective supportive measure in COVID-19 patients. Target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92% in pregnant patients. Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or convulsions) should receive oxygen therapy during resuscitation to target SpO2 ≥94%; otherwise, the target SpO2 is ≥92%. Titrate oxygen therapy up and down to reach targets by means of a nasal cannula, simple facemask or facemask with reservoir bag, as appropriate.
1. Oxygenation and Ventilation
Non invasive oxygenation
• Low Flow nasal canula
• Simple face mask
• Non – rebreather Mask
• Cpap face mask
• Bag-valve mask (ambu bag)
• High Flow Nasal Canula
Invansive oxygenation
• Mechanical ventilating machine
a. Low Flow nasal canula
Indications/Descriptions
• For mild hypoxemia (SPO2- <94% >90%)
• Oxygen delivered 1-6lts/min
• Can deliver up to 22%-45% FiO2 on 1- 6L/min
• Higher rates of flow (>4L/min) may lead to nasal irritation
Source of oxygen
• Oxygen concentrator
OR
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold
Comments
• Clinical judgement should be used for the indication.
• Close monitoring is important for decision making of type of appliance to be used.
• General observation, by the use of the same appliance, there is much improvement on Cylinders rather than concentrator (when available) oxygen cylinder is a better option to concentrator
b. Simple face mask
Indications/Descriptions
• For moderate hypoxia (SPO2<89%
• Can deliver 40%-60% FiO2 on 6-10L/min
• Flow <5L/min does not flush out the CO2 in the mask.
Source of oxygen
• Oxygen concentrator
OR
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold
Comments
• Delivers an intermediated flow of oxygen (6-10lts/min
• Clinical judgement including respiratory rate (RR) should be used for the indication
c. Non – rebreather Mask
Indications/Descriptions
• Can provide 85%-95% FiO2 on 10- 15L/min.
Source of oxygen
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold
Comments
• Can deliver low and high flow oxygen
d. Cpap face mask
Indications/Descriptions
• These provide positive pressure or oxygen without need of intubation
• May be full-face mask or just covering nose and mouth.
• FiO2 is selected on the device (CPAP or ventilator machine)
Source of oxygen
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold.
Comments
• Delivers high flow oxygen.
• Indicated for complications like pulmonary oedema, it should be used regardless of the room condition (To avoid exposure to aerosols all healthcare workers should be on N95 and face shield.
• Clinical judgement, and patient’s response should be applied.
• Non-rebreather mask is superior to CPAP for oxygen delivery in COVID-19 patients.
e. Bag-valve mask (ambu bag)
Indications/Descriptions
• Has self-inflating bag, a valve and a mask
• Select the size according to age
• It provides positive pressure ventilation
• Procedure is called Bag valve-Mask Ventilation.
• Provides oxygen up to Fio2 of 100%
Source of oxygen
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold.
Comments
• Indicated for patients with signs of typical respiratory failure (no visible active breathing)
• Adherence to standard and additional IPC precautions should be applied.
f. Bag-valve mask (ambu bag)
Indications/Descriptions
• Can administer up to 10-60L of humidified warmed oxygen (2L/kg/min up to 12kg)
• Can be used in pediatric as well as adult patients
Source of oxygen
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold.
Comments
• Knowledge needed to set up pressure or volume required
• May be implemented and managed by non-ICU specialists outside ICU
• Does not require invasive monitoring
• Does not need as intensive nursing care as for invasive ventilation
• Can be combined with awake self- prone
• May be a lower-resource alternative to mechanical ventilation in some patient
g. High Flow Nasal Canula
Indications/Descriptions
• For failure of oxygenation or ventilation despite being kept on Bag Valve Mask Ventilation or CPAP
• Can provide FiO2 as selected on the machine, as well as positive pressure depending on setting done.
Source of oxygen
• Oxygen Cylinder
OR
• Central source from oxygen plant or manifold.
Comments
• It’s made for up to 100% oxygen delivery.
• Complicated, requires well trained staff and full ICU requirements.
• Standard and additional IPC precautions should be adhered during care of those patients.
2. Note
The use of the prone position in non-intubated, conscious patients who are hypoxemic may be beneficial. Patients who have respiratory failure despite maximal facemask oxygen should be promptly identified and evaluated for possible escalation of respiratory support. Possible modalities include high flow nasal cannula oxygen, continuous positive airway pressure, or intubation and mechanical ventilation.
3. Recognize severe hypoxemic respiratory failure
Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy.
Patients may continue to have increased work of breathing or hypoxemia (SpO2 <90%, PaO2 <60 mmHg [<8.0 kPa]) even when more than 10l/min oxygen is delivered via a face mask with reservoir bag. Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation- perfusion mismatch or shunt and usually requires mechanical ventilation.
In the absence of an indication for endotracheal intubation, a trial of high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP) or other non-invasive ventilation (NIV) technique may be considered for adults with Covid-19 and acute hypoxemic respiratory failure failing standard oxygen therapy.
Patients receiving HFNO, CPAP or other NIV should be in a closely monitored setting and cared for by experienced personnel capable of endotracheal intubation if the patient acutely deteriorates. Intubation should not be delayed in such circumstances.
Updated,
25 Machi 2021, 07:24:57
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