Management of patients with pneumonia or comorbidities
Promptly admit patients with pneumonia or respiratory distress to an appropriate healthcare facility and
start supportive care depending on the clinical presentation. The median time from onset of symptoms to
hospital admission is reported to be approximately 7 days.[4] [6] Patients with impending or established
respiratory failure should be admitted to an intensive care unit. Between 23% to 32% of hospitalised
patients require intensive care for respiratory support.[4] [5] [6] However, this estimate may be lower
based on current case counts. Symptomatic patients who no longer require hospitalisation may be
considered for home care if suitable (see below).
Supportive therapies
• Oxygen: give supplemental oxygen at a rate of 5 L/minute to patients with severe acute respiratory
infection and respiratory distress, hypoxaemia, or shock. Titrate flow rates to reach a target SpO₂
≥90%.[68]
• Fluids: manage fluids conservatively in patients with severe acute respiratory infection when there
is no evidence of shock as aggressive fluid resuscitation may worsen oxygenation.[68]
• Symptom relief: give an antipyretic/analgesic for the relief of fever and pain.[68]
• Antimicrobials: consider starting empirical antimicrobials in patients with suspected infection
to cover other potential bacterial pathogens that may cause respiratory infection according
to local protocols. Give within 1 hour of initial patient assessment for patients with suspected
sepsis. Choice of empirical antimicrobials should be based on the clinical diagnosis, and
local epidemiology and susceptibility data. Consider treatment with a neuraminidase inhibitor
until influenza is ruled out. De-escalate empirical therapy based on test results and clinical
judgement.[68] Some patients with severe illness may require continued antimicrobial therapy once
COVID-19 has been confirmed depending on the clinical circumstances.
Monitoring
• Monitor patients closely for signs of clinical deterioration, such as rapidly progressive respiratory
failure and sepsis, and start general supportive care interventions as indicated (e.g., haemodialysis,
vasopressor therapy, fluid resuscitation, ventilation, antimicrobials) as appropriate.[68]
Mechanical ventilation
• It is important to follow local infection prevention and control procedures to prevent transmission to
healthcare workers. Endotracheal intubation should be performed by an experienced provider using
airborne precautions.
• Intubation and mechanical ventilation are recommended in patients who are deteriorating and
cannot maintain an SpO₂ ≥90% with oxygen therapy.[68] Some patients may develop severe
hypoxic respiratory failure, requiring a high fraction of inspired oxygen, and high air flow rates to
match inspiratory flow demand. Patients may also have increased work of breathing, demanding
positive pressure breathing assistance.
• High-flow nasal oxygen and non-invasive ventilation are recommended in select patients.
Mechanically ventilated patients with acute respiratory distress syndrome should receive a lungprotective, low tidal volume/low inspiratory pressure ventilation strategy. Those with persistent
severe hypoxic failure should be considered for prone ventilation.[68]
• The risk of treatment failure is high in patients with non-acutely reversible conditions, and there is
also concern about nosocomial transmission with open ventilation systems and suboptimal noninvasive face mask or nasal pillow seals. More research to define the balance of benefits and risks
to patients and health workers is needed.
• Some patients may require extracorporeal membrane oxygenation (ECMO) according to availability
and expertise.