This is a really important question, ‘What is the treatment for COVID-19?’ The answer is that we don’t know the ‘perfect’ treatment or even the ‘best treatment.’ Patients who have tested positive for a COVID-19 antibody test across the U.S. and around the world have been receiving individualized ‘Supportive care.”
Supportive care is defined by MedicineNet.com as “treatment given to prevent, control, or relieve complications and side effects and to improve the patient’s comfort and quality of life.” Basically, the physicians and staff assess the patient’s condition and work to support and provide whatever is needed for that patient. When a patient shows COVID-19 symptoms of fever, being short of breath and coughing, this patient might receive IV fluids to prevent dehydration, oxygen therapy and other treatments. The patient who calls the COVID-19 hotline with mild symptoms of fatigue, loss of appetite, and achy muscles might receive instructions to stay at home and use symptoms management such as drinking plenty of liquids, getting extra rest and using over-the-counter fever medications. The patient would be instructed to call them back, call the local ER or call 911 for immediate medical care if symptoms worsen.
Treatments being utilized during the COVID-19
Besides the individualized supportive care patients are receiving, there are some innovative treatments being done around the world. We will discuss a few such as supplemental oxygen, ventilator vs. no ventilator, proning, convalescent plasma, drugs which include the antimalarial drugs, the Ebola drug Remdesivir, anticoagulants and a vaccine.
Supportive Care includes supplemental oxygen.
Patients who are dealing with respiratory symptoms can and do receive supplemental oxygen without being intubated and ventilated. Supplemental oxygen using a nasal cannula or face-mask setup can deliver increased oxygen to patients and ease the respiratory effort. Patients receiving supplemental oxygen will also be monitored to ensure adequate oxygenation. If a finger probe is on the patient’s finger, you know the oxygen level (pulse oximetry) is being monitored. There are multiple ways to monitor oxygen level with pulse oximetry being a reliable, external method. By monitoring the oxygen level, the medical and nursing staff will know if the patient’s respiratory status is deteriorating and if a ventilator is needed.
Ventilator vs. no ventilator oxygen therapy
Ventilator vs. no ventilator oxygen therapy. Early during the pandemic, patients who lacked the ability to breathe deeply and oxygenate themselves were placed on a ventilator. (We have all heard of the expected need for massive numbers of ventilators which has not materialized so far, thank goodness.) Those critically ill patients with respiratory inability to breathe deeply enough were intubated (a breathing tube placed down the throat into the trachea) and connected to a ventilator which breathes for them. Ventilators are used daily in hospitals around the world and are life-saving machines.
Ventilators require special care and have risks
- Ventilators require special expertise by medical, nursing and respiratory therapy staff.
- Patients are usually sedated because it’s uncomfortable having a tube in your throat and a machine breathing for you. (You probably heard about shortages of the drugs used to sedate patients while on a ventilator.)
- Ventilators add a risk of developing pneumonia (lung infection) because bacteria can enter the lungs.
- The patient cannot cough effectively while on a ventilator so what starts as a viral infection can become a bacterial infection. (Doctors call that “superinfection” meaning more than one infection which complicates the needed supportive care.)
- Another issue with ventilators involves coming off the ventilator as a patient heals and recovers; this is called ‘weaning’ off the ventilator. Weaning a patient off the ventilator involves multiple steps of decreasing the ventilator while supporting and monitoring the patient’s respiratory efforts. Weaning off the ventilator often takes several days. Be assured the intensive care unit (ICU) staff have established protocols for this patient transition back to breathing independently and the staff will be closely monitoring the patient throughout this process.
- Ventilators can damage a person’s lungs and the longer time a patient is on a ventilator, the increased risk of lung damage.
Current treatment delays ventilator usage
In New York, early reports of up to 80% of COVID-19 patients who were placed on ventilators were dying and caught the attention of the medical community. Were these patients dying because of the COVID-19 infection damage or was the ventilator usage increasing the risks for these patients? No one knows, but as a cautionary measure, physicians are waiting until they feel like it’s absolutely necessary to save the patient’s life before starting the ventilator treatment.
Supportive Care involves how the patient is positioned.
The term “Proning” has been used to describe the patient lying on his stomach (prone position). This positioning takes chest cavity weight off the lungs. Most hospitalized patients are positioned on their backs with frequent turning and repositioning to either side to prevent pressure areas. So “proning” a patient is a technique being utilized during the COVID-19 pandemic with great success. In fact, a WebMD article on May 6, 2020, describes this as a “simple, noninvasive technique that could delay, or even eliminate the need for ventilation in COVID-19 patients.”
Early supportive care did not include “proning.” Doctors saw patients who needed respiratory help and wanted to avoid the dangers of ventilators if possible. A small study involving 50 adult COVID-19 patients was held during the month of March 2020 at the New York City Health and Hospitals/Lincoln Medical and Mental Health Center. All the patients showed hypoxia (low oxygen levels). After adding supplemental oxygen, the patients improved slightly but not enough. When the staff began to turn patients into a prone position, their oxygen levels improved greatly and almost 75% of them did not require a ventilator.
Convalescent plasma treatment involves a person who has recovered from the COVID-19 illness (symptom free for fourteen days and eligible to donate blood), donating blood at Red Cross or a variety of approved blood bank facilities. At the blood bank, the plasma (pale yellow liquid part) is separated from the other blood products and then this plasma (convalescent plasma) is given to critically ill patients fighting the COVID-19 infection using blood transfusion techniques.
You may be wondering why convalescent plasma has value for patients fighting COVID-19. Remember, in the blog post “What is a coronavirus” we discussed what happens in our bodies when we are exposed to COVID-19? Our immune system has two components: the innate immune system which recognizes the virus as a foreign, dangerous substance and begins to mobilize the body’s ability to fight it. The second component of our immune system is called the acquired immune response and it stimulates our body to make antibodies. Antibodies help us fight the disease and protect us from future re-infection by the antigen (in this case, the COVID-19 virus). So convalescent plasma treatment gives the critically ill patient the antibodies from the recovered blood donor patient.
This promising treatment has been expanded into an early safety study being supported by the US Government and Mayo Clinic researchers. This study includes 5000 patients who received convalescent plasma between April 3 and May 3, 2020. Sixty-six percent of the 5000 patients were ICU patients and 20% of those were critically ill with multi-organ dysfunction or failure (meaning their body systems were not functioning properly and/or shutting down, a life-threatening diagnosis). The mortality (death) incidence was 14.9 at seven days and the overall serious adverse events (which included events that can occur with routine blood transfusions) were listed as ＜1% after convalescent plasma treatment.
During the individualized Supportive Care that each patient dealing with COVID-19 receives, a lot of different medications are used to support and treat. We will not attempt to discuss all the medications potentially needed, but rather discuss a few that have been mentioned in the news. Two drugs that have been discussed a lot include the antimalarial drugs chloroquine (Aralen Phosphate or Arlene Hydrochloride) and hydroxychloroquine (Plaquenil). Both these drugs are used to prevent and treat malaria (a parasite carried and passed to people via mosquito bites. Hydroxychloroquine is also used as an anti-inflammatory drug in the treatment of rheumatoid arthritis and systemic lupus erythematosus.
Both drugs have been approved for emergency use by the U.S. Food and Drug Administration during the COVID-19. More than 830,000 prescriptions for hydroxychloroquine were filled during March 2020 which is more than double the March 2019 numbers.
However, a study reported on May 22, 2020 evaluated 96,000 patients from 671 hospitals in The Lancet. The researchers reported they found no benefit to hydroxychloroquine or chloroquine for patients ill with COVID-19 while they found an increased risk of cardiac arrhythmias and death. Studies about whether these drugs will help prevent the COVID-19 infection are still underway. As with all medications, physicians will consider a patient’s health status and the risks to that patient when ordering these two medications.
Remdesivir is another drug that received emergency use approval from the FDA for COVID-19 patients. Remdesivir was developed to treat Ebola (a different virus which became famous during 2014-6 when it caused a hemorrhagic fever in humans. Ebola outbreaks occurred predominantly in Africa and caused high mortality rate among those who became infected). Scientists have studied how Remdesiriv works and recognize the drug interferes with the virus reproducing itself. So early treatment with remdesivir gives the best results.
A preliminary study report published in the New England Journal of Medicine on May 22, 2020, reported that remdesivir-treated patients recovered quicker (11 instead of 15 days) and fewer died when compared to patients who received a placebo. This drug continues to look like effective treatment for COVID-19 patients.
Antibiotics are not considered beneficial treatment for COVID-19 because antibiotics kill bacteria, not viruses. However, antibiotics are being included in the treatment of some COVID-19 patients, especially those who develop a bacterial superinfection. (See Ventilators require special care and have risks in this blog post). One of the antibiotics being used to treat COVId-19 patients who develop superinfections is azithromycin (Zithromax, Z-pack). Also scientists think that azithromycin may have some antiviral properties when given with other COVID-19 treatments.
Systemic anticoagulation therapy
People who respond to the COVID-19 with the cytokine storm become very ill. Think of a running wild immune system which starts to attack the person’s organs such as kidneys, lungs, and cardiovascular system (heart and blood vessels). For such a patient, blood clotting abnormalities may occur and anticoagulation therapy might be necessary to save the person’s life. Anticoagulation therapy might involve low-molecular weight heparin or other anticoagulants. If needed, anticoagulation therapy will be monitored and managed throughout treatment.
Nitric oxide COVID-19 treatment
Nitric oxide isn’t a treatment we have heard much about. This respiratory treatment has been used for the past 20 years to treat serious respiratory and heart issues. It has been researched as a treatment to prevent kidney damage for patients undergoing prolonged cardiac valve replacement surgery. Nitric oxide was used for selected patients during the 2003 SARS (caused by a different coronavirus) outbreak.
The usage of nitric oxide for COVID-19 involves a portable inhaler device. Physicians recognize that nitric oxide dilates the respiratory anatomy of trachea and bronchioles and the arteries of the body. The increased airways and arteries promote better ventilation and blood supply throughout the body. Whether nitric oxide will prove to be an additional treatment for COVID-19 patients, we do not know. Research is currently underway.
Currently there are multiple pharmaceutical companies world-wide working to develop a vaccine which will protect people from the COVID-19 virus. We expect a vaccine to be developed, the question is when.
So, as we think of the COVID-19 treatments, we remember that the COVID-19 is a new (novel) virus which has alarmed us and surprised doctors as they work hard to care for patients and save lives. We have only begun to answer the question, “What is the treatment for COVID-19?” Currently, there is no one ‘best treatment for COVID-19. Doctors, nurses and other healthcare professionals begin with Supportive Care as they assess, diagnose and treat each patient as an individual person.
In the meantime, remember how we can protect ourselves from the COVID-19 virus. Practice social distancing, wear a mask, keep your hands off your face (especially if you have touched potentially infectious items) and wash our hands often. Use hand sanitizer if soap and water are not available. Remember, the COVID-19 virus cannot hurt us until it enters our bodies (nose, eyes and mouth are easily accessible to the virus).
Researchers and physicians have cared for patients and learned about the COVID-19 virus and how it affects us. There is still much unknown about the virus and the best treatments. When searching for accurate medical information, use reputable medical websites such as CDC, WebMD, and Cleveland Clinic. They provide trustworthy and up-to-date information about COVID-19. We recommend that people use reputable websites rather than internet gossip when dealing with their health, including the COVID-19 pandemic.