Oxygen FAQ

Pulse oximetry plays a key role in the diagnosis, triage and management of COVID-19 patients. This includes when to initiate hospitalization or oxygen therapy and when to escalate or deescalate oxygen therapy. This can be an essential tool for conserving oxygen supply as well. 

Hypoxemia is a key finding in many patients with COVID-19. Up to 80% of patients with COVID-19 may have only mild symptoms or be completely asymptomatic. Common initial symptoms of COVID-19 infection include fever, cough, headache, fatigue, and myalgias. About 15% of infected patients develop severe disease, and about 5% develop critical illness – these patients may require supplemental oxygen. It has been reported that many patients with COVID-19 have more significant hypoxemia than their symptoms might suggest, which has been referred to as “happy” or “silent”  hypoxia. Therefore, it is essential to check SpO2 for all patients with known or suspected COVID-19 infection who are symptomatic or report for medical evaluation.  

References: Lifebox Pulse Oximetry Learning Module

Keywords: COVID-19, symptomatic, shortness of breath, SOB, coronavirus, oxygen

The optimal SpO2 for patients with respiratory failure has not been well established and is still being evaluated. The World Health Organization (WHO) guidance for patients with hypoxemic respiratory failure due to COVID-19 recommends the following targets: Initial SpO2 of >94% for stabilization, then >90% for stable patients who are not pregnant or 92-95% for stable patients who are pregnant. It is important not to make SpO2 goals too high, as this can cause oxygen toxicity and will deplete the oxygen supply more quickly. For more discussion on optimal SpO2 goals in patients with respiratory failure, please read more here.

References: WHO SARI Toolkit 

Keywords: target SpO2, goal, respiratory failure, COVID-19

The service manual is available to certified/trained service partners. Of note, to perform a PM for the vent an external service tool (called RCS) is required.

▪ Test to Treat (sometimes abbreviated as “T2T”) is a strategy to streamline early COVID-19 diagnosis and prompt treatment with oral antiviral drugs for patients at increased risk of severe COVID-19.

▪ Step one (“Test”) is to identify symptomatic patients within five days of symptom onset and perform a test— ideally a rapid diagnostic test—to confirm COVID-19 infection.

▪ Step two (“to Treat”) is to identify patients who are at high risk for developing severe illness or death from COVID-19 and initiate oral antiviral treatment in such patients.

▪ In the Test to Treat strategy, all positive COVID-19 patients can have streamlined access to evidence-based care, even if they are not eligible for oral antivirals, and all patients should be educated and monitored throughout the course of their illness for symptom resolution.

-By EPiC FHI360

Anyone with symptoms should be tested, even if symptoms are mild. Symptoms include fever, cough, fatigue, loss of taste and smell, shortness of breath, sore throat, runny nose/congestion, body aches/muscle aches and, sometimes, nausea, vomiting, and/or diarrhea. It is especially important to test as early as possible once symptoms start, as oral antivirals are only effective if started within five days of symptom onset.

-By EPiC FHI360

▪ Two antiviral medications are effective and approved for Test to Treat: Paxlovid (nirmatrelvir/ritonavir, or NMV/r) and Lagevrio (molnupiravir, MOL). These are intended to be used in outpatient (non-hospitalized) settings. Generic versions of these medications are anticipated in upcoming months – continue to be attentive to local guidelines regarding specific details and availability.

▪ There are other treatments indicated for patients with more severe disease requiring advanced levels of care (i.e., treatment in a hospital due to severe or critical COVID-19). The goal of oral antiviral therapy is to reduce the risk of requiring an advanced level of hospital care and reduce the risk of death.

-By EPiC FHI360

▪ Symptomatic COVID-19 patients, confirmed with a positive test, within five days of onset of symptoms, and who are at risk for progression to severe disease.

▪ Patients must be age 12 or older and weigh at least 40 kilograms (88 pounds) to take NMV/r, and age 18 years or older to take MOL, but generally, the Test to Treat strategy is geared to adult patients with risk factors for developing complications.

▪ Risk factors for developing severe or critical COVID-19 include (but not limited to): Older than age 50; risk increasing substantially at age 65 and above; Chronic medical diseases such as pulmonary/lung disease, hypertension, diabetes, chronic kidney disease, immunocompromised state, HIV infection, obesity (BMI > 30kg/m2)

▪ See treatment algorithm and other resources for more details

-By EPiC FHI360

▪ Asymptomatic patients even if they have a positive COVID-19 test

▪ Symptomatic patients with only negative COVID-19 tests

▪ Patients who do not have risk factors for developing severe or critical COVID-19

▪ Patients who have had symptoms for more than five days

▪ (For NMV/r only) Patients who have severe kidney or liver disease (see clinical guidance materials)

▪ Patients who are allergic to any of the ingredients in the medication

▪ Patients who cannot swallow whole tablets; oral antiviral pills should not be cut or crushed and must be swallowed whole

▪ (For NMV/r only) Patients who are using other drugs that cannot be discontinued or doseadjusted that may result in potentially significant drug-drug interactions with NMV/r.

Patients not eligible for oral antivirals can be reassured that they are receiving person-centered, evidence-based care and be advised on how to treat symptoms safely at home, even if they don’t get a prescription for antivirals.

-By EPiC FHI360

▪ It is important to reconcile or update a patient’s current medication list prior to starting oral antiviral therapy. There are important drug-drug interactions (especially for NMV/r), and there are several resources to guide dosing adjustments and/or interruptions as a patient completes their course of antiviral therapy (for example https://www.covid19- druginteractions.org/).

▪ The dosage for Paxlovid is 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet), with all three tablets taken together orally twice daily for five days. The full five-day course should be completed in conjunction with continued isolation according to public health recommendations.

▪ The dosage for Lagevrio (molnupiravir) is 800 mg (four 200 mg capsules) orally, every 12 hours for five days. The full five-day course should be completed in conjunction with continued isolation according to public health recommendations.

▪ The drugs can be taken with or without food. The tablets or capsules should not be cut, crushed, or broken. ▪ Drug-drug interactions should be considered; specific details and recommendations for dose adjustments can be found on the Test to Treat antiviral therapy algorithm

-By EPiC FHI360

▪ No pre-treatment renal (kidney) laboratory tests or hepatic (liver) laboratory tests are required or recommended to start oral antiviral therapy.

▪ If a patient has known chronic kidney disease with a recent eGFR of 30–60, consider adjusting the dose of NMV/r per the renal dosing guidelines. If a patient has known advanced kidney disease with eGFR < 30, NMV/r should not be prescribed. Evaluate the patient for the use of molnupiravir.

▪ If a patient does not have a recent eGFR but there is high suspicion of advanced renal disease, use clinical judgment to decide if the benefit of NMV/r outweighs the risk and/or if you can get laboratory values back in a timely manner to manage the patient accordingly.

▪ If the patient has known severe hepatic (liver) impairment disease, NMV/r should not be prescribed. Evaluate the patient for the use of molnupiravir.

▪ A pregnancy test is not required.

-By EPiC FHI360