Severe Covid-19: A NEJM case report
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This article begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.

A 50-year-old, previously healthy man presents to the emergency department with 2 days of worsening dyspnea. He had fever, cough, and fatigue during the week before presentation. He appears acutely ill. The body temperature is 39.5°C (103°F), heart rate 110 beats per minute, respiratory rate 24 breaths per minute, and blood pressure 130/60 mm Hg. The oxygen saturation is 87% while the patient is breathing ambient air. The white-cell count is 7300 per microliter with lymphopenia. Chest radiography shows patchy bilateral opacities in the lung parenchyma. A reverse-transcriptase–polymerase-chain-reaction assay detects the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in a nasopharyngeal swab. How to evaluate and manage this case?

Key clinical points about evaluation and management of Severe Covid-19:

-- Patients with severe Covid-19 may become critically ill with acute respiratory distress syndrome that typically begins approximately 1 week after the onset of symptoms.
-- Deciding when a patient with severe Covid-19 should receive endotracheal intubation is an essential component of care.
-- After intubation, patients should receive lung-protective ventilation with plateau pressure less than or equal to 30 cm of water and with tidal volumes based on the patient’s height.
-- Prone positioning is a potential treatment strategy for refractory hypoxemia.
-- Thrombosis and renal failure are well-recognized complications of severe Covid-19.
-- Data are needed from randomized trials to inform the benefits and risks of antiviral or immunomodulatory therapies for severe Covid-19; as of mid-May 2020, no agents had been approved by the Food and Drug Administration for treatment of these patients.
-- Preliminary data from a randomized, placebo-controlled trial involving patients with severe Covid-19 suggest that the investigational antiviral remdesivir shortens time to recovery.

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