COVID-19 TREATMENT GUIDELINEIN TANZANIA, MARCH 2021
Posted by ULY CLINIC
24 Machi 2021 19:20:48
The guidance 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.
NOTE. THIS GUIDELINE IS THE POPERTY OF MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN
Prone positioning has been shown to improve oxygenation in spontaneously breathing, non- intubated non-Covid-19 patients with hypoxemic acute respiratory failure. Consequently, its potential value in the management of patients with Covid-19 pneumonia has been explored. A management strategy involving early intervention and awake proning with high-flow nasal cannula or non-invasive mechanical ventilation to prevent alveolar collapse resulted in lower intubation and mortality rates has been observed in different health care facilities. Some studies have demonstrated that application of self-proning with HFNC may help avoid intubation.
a. Physiological Effects Of Proning
The physiological benefits of prone positioning that should apply to all patients regardless of whether they are intubated or not, include:
• Improved Ventilation/Perfusion (VQ) matching and reduced hypoxemia (secondary to more homogeneous aeration of lung and ameliorating the ventral-dorsal trans- pulmonary pressure gradient – more uniform lung ventilation, better distribution of air flow and better matching of areas that receive
oxygen and appropriate blood flow).
• Reduced shunt (perfusion pattern remaining relatively constant while lung aeration becomes more homogenous – better matching of areas that have blood flow to receiving oxygen).
• Recruitment of the posterior lung segments due to reversal of atelectasis; Improved secretion clearance.
b. Different approaches to positional adjustment in COVID-19
Various approaches have been attempted.
• Complete pronation (with the patient lying on their abdomen, ideally for 16-18 hours per day) as in prone intubated patients would be optimal. However, this can be difficult in many patients e.g. with obesity.
• Another approach is to rotate positions, including lying on either side and sitting bolt upright which may be easier for many patients to tolerate. Some health care facilities encourage mobilization via walking of selected Covid-19 patients.
• Proning for a few hours with a return to supine position may lead only to transient improvements in oxygenation. Longer-lasting benefit might result from longer periods of pronation, or strategies involving ongoing rotation between several different positions. The key principle is to avoid spending much time in a flat, supine position.
• As one suggested approach, we suggest following the UK Intensive Care Society’s proning recommendations as outlined below.
• Awake pronation appears to be a safe, inexpensive, and versatile strategy which can be used at all levels across a variety of different healthcare settings.
c. Assist Patient To Prone Position
• Explain procedure/benefit
• Get consent from the patient
• Ensure oxygen therapy and basic respiratory support secure with adequate length on the tubing
• Pillows may be required to support the chest
• Reverse trendelenberg position may aid comfort
• Monitor oxygen saturations If drop then ensure O2 connected and working
• Sedation must not be administered to facilitate proning
Pictures of proper prone position
Click to expand pictures on the top of this chapter for various prone positions
d. What to check while proning?
Oxygen Saturations For 15 Minutes
SaO2 92-96% (88-92% if risk of hypercapnia respiratory failure) and nil obvious distress
Continue Proning Process
• Change positions every 1-2 hrs, aiming to achieve a prone time as long as possible
• When not prone aim to be sat at between 30-60 degrees’ upright
• Monitor oxygen saturations after every position change
• Titrate down oxygen requirements as able
If Deteriorating Oxygen Saturations:
• Ensure oxygen is connected to patient
• Increase inspired oxygen
• Change patients position
• Consider return to supine position Escalate to critical care if appropriate Discontinue if no improvement with change of position, Patient unable to tolerate position, looks tired and using accessory muscles
NB: For ICU intubated patients’ needs a closer monitoring
e. Contraindication Of Proning
• Respiratory distress (RR 35, PaCO2 6.5, accessory muscle use)
• Immediate need for intubation
• Hemodynamic instability (SBP < 90mmHg) or arrhythmia
• Agitation or altered mental status
• Unstable spine/thoracic injury/recent abdominal surgery
• Facial injury
• Neurological issues (e.g. frequent seizures)
• Morbid obesity
• Pregnancy (2/3rd trimesters)
• Pressure sores / ulcers
25 Machi 2021 06:49:46
1. THE UNITED REPUBLIC OF TANZANIA. MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDRENCORONAVIRUS DISEASE 2019 (COVID-19) TREATMENT GUIDELINES. MARCH 2021
2. Del Rio, C. and P.N. Malani, (2020). 2019 Novel Coronavirus—Important Information for Clinicians. JAMA, 2020. 323(11): p. 1039-1040.
3. World Health Organization, (2020). Coronavirus disease 2019 (COVID-19) Situation Report 46, 2020.
4. World Confederation of Physical Therapists (WCPT) (2020). Physiotherapy management for COVID 19 version 1.0 23 March 2020
5. Sohrabi, C., Z. Alsafi, N. O'Neill, M. Khan, A. Kerwan, A. Al-Jabir, C. Iosifidis, and R. Agha, (2020). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg, 2020. 76: p. 71-76.
6. Guan, W.-j., … Ye, C.-j. Zhu, S.-y. and Zhong N.-s., (2020). Clinical Characteristics of Coronavirus Disease 2019 in China. NewEngland Journal of Medicine, 2020.
7. van Doremalen, N., … Lloyd-Smith, J.O., de Wit, E., and Munster, V.J., (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine, 2020.
8. Yoon, S.H., K.H. Lee, J.Y. Kim, Y.K. Lee, H. Ko, K.H. Kim, C.M. Park, and Y.H. Kim, Chest Radiographic and CT Findings of the 2019 Novel Coronavirus Disease (COVID-19): Analysis of Nine Patients Treated in Korea. Korean J Radiol, 2020. 21(4): p. 494-500.
9. Zhao, D., F. Yao, L. Wang, L. Zheng, Y. Gao, J. Ye, F. Guo, H. Zhao, and R. Gao, A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clin Infect Dis, 2020.
10. Peng, Q.Y., X.T. Wang, L.N. Zhang, and G. Chinese Critical Care Ultrasound Study, Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med, 2020.
11. Chen, N., M. Zhou, X. Dong, J. Qu, F. Gong, Y. Han, Y. Qiu, J. Wang, Y. Liu, Y. Wei, J. Xia,
T. Yu, X. Zhang, and L. Zhang, Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet, 2020. 395(10223): p. 507-51s3.
12. Zhou, F., T. Yu, R. Du, G. Fan, Y. Liu, Z. Liu, J. Xiang, Y. Wang, B. Song, X. Gu, L. Guan, Y. Wei, H. Li, X. Wu, J. Xu, S. Tu, Y. Zhang, H. Chen, and B. Cao, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 2020.
13. Xie, J., Z. Tong, X. Guan, B. Du, H. Qiu, and A.S. Slutsky, Critical care crisis and some recommendations during the COVID-19 epidemic in China. Intensive Care Medicine, 2020.
14. Australian and New Zealand Intensive Care Society, ANZICS COVID-19 Guidelines, 202, ANZICS: Melbourne.
15. Kress, J.P. and J.B. Hall, (2014). ICU-acquired weakness and recovery from critical illness.
N Engl J Med, 2014. 370(17): p. 1626-35.
16. Herridge, M.S., C.M. Tansey, A. Matte, G. Tomlinson, N. Diaz-Granados, A. Cooper, C.B. Guest, C.D. Mazer, S. Mehta, T.E. Stewart, P. Kudlow, D. Cook, A.S. Slutsky, and A.M. Cheung, (2011). Functional disability 5 years after acute respiratory distress syndrome. N Engl JMed, 2011. 364(14): p. 1293-304.
17. Brouwers, M.C., M.E. Kho, G.P. Browman, J.S. Burgers, F. Cluzeau, G. Feder, B. Fervers,
I.D. Graham, S.E. Hanna, and J. Makarski, (2010). Development of the AGREE II, part 1: performance, usefulness and areas for improvement. Cmaj, 2010. 182(10): p. 1045-52.
18. Schunemann, H.J., …Cuello, R. Waziry,and Akl, E.A., (2017). GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol, 81: p. 101-110.
19. Moberg, J., A.D., …Morelli, G. Rada, and P. Alonso-Coello, (2018). The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst, 16(1): p. 45.
20. Clinical Skills Development Service, Q.H. Physiotherapy and Critical Care Management eLearning Course. Accessed 21/3/20]; Available at https://central.csds.qld.edu.au/central/courses/108].
21. World Health Organisation, (2020). Infection prevention and control during health care when COVID-19 is suspected: Interim Guidance, M. 2020, Editor 2020.
22. Queensland Health,(2020). Clinical Excellence Division COVID-19 Action Plan: Statewide General Medicine Clinical Network,
23. The Faculty of Intensive Care Medicine. (2019). Guidelines for the provision of the intensive care services.; Available from: https://www.ficm.ac.uk/news-eventseducation/ news/guidelines-provision-intensive-care-services-gpics-%E2%80%93-secondedition.
24. Alhazzani, W., … Hayden, F., Evans, L., and Rhodes, A., (2019). Surviving sepsis campaign: Guidelines of the Management of Critically Ill Adults with Coronavirus Disease (COVID- 19). Critical Care Medicine, 2020. EPub Ahead of Print.
25. World Health Organization, (2020). Clinical Management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected Interim Guidance, 2020. p. WHO Reference number WHO/2019-nCoV/clinical/4.
26. Metro North, (2020). Interim infection prevention and control guidelines for the management of COVID-19 in healthcare settings,: https://www.health.qld.gov.au/ data/assets/pdf_file/0038/939656/qh-covid-19- Infectioncontrol- guidelines.pdf.
27. Stiller, K., (2013). Physiotherapy in intensive care: an updated systematic review. Chest,
144(3): p. 825-847.
28. Green, M., V. Marzano, I.A. Leditschke, I. Mitchell, and B. Bissett, (2016). Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscipline Health, 9: p. 247-56.
29. Hodgson, C.L. Zanni, L. Denehy, and S.A. (2014). Webb, Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 2014. 18(6): p. 658.
30. Australian and New Zealand Intensive Care seeliery, ANCS COVID 19 Guidelines 202 ANZICS Melhsore.
31. Zanni, M.J., denehy,L.(2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical care. 18 (6): p 658.