Severe Covid-19

David A. Berlin, M.D., Roy M. Gulick, M.D., M.P.H., and Fernando J. Martinez, M.D.

KEY CLINICAL POINTS

Patients with severe coronavirus disease 2019 (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.