7. • Fever, cough, sore throat, nasal
congestion, malaise, headache
Uncomplicated
illness
• Patient with pneumonia and no
signs of severe pneumonia.
• Child have cough or difficulty
in breathing/ fast breathing:
(fast breathing - in breaths/min):
• <2 months, ≥60;
• 2–11 months, ≥50;
• 1– 5 years, ≥40 and no signs of
severe pneumonia
Mild
pneumonia
8. • Adolescent or adult: fever or
suspected respiratory infection,
plus one of the following; respiratory
rate >30 breaths/min, severe
respiratory distress, SpO2 <90% on
room air.
• Child with cough or difficulty in
breathing, plus at least one of the
following :
• SpO2 <90%; severe respiratory
distress.
• Signs of pneumonia with any of the
following danger signs: inability to
breastfeed or drink, lethargy or
unconsciousness, or convulsions.
• Other signs of pneumonia may be
present: chest indrawing, fast
breathing (in breaths/min): <2 months
≥60; 2–11 months ≥50; 1–5 years ≥40.
9. • Onset: new or worsening
respiratory symptoms within one
week of known clinical insult.
• Chest imaging (radiograph, CT
scan, or lung ultrasound):
bilateral opacities, not fully
explained by effusions, lobar or
lung collapse, or nodules.
• Origin of oedema: respiratory
failure not fully explained by
cardiac failure or fluid overload.
• Need objective assessment (e.g.
echocardiography) to exclude
hydrostatic cause of oedema if
no risk factor present.
Acute
Respiratory
Distress
Syndrome
10. • Adults: life-threatening organ
dysfunction include:
• altered mental status, difficult or
fast breathing, low oxygen
saturation, reduced urine output,
fast heart rate, weak pulse, cold
extremities or low blood pressure,
skin mottling, or laboratory
evidence of coagulopathy,
thrombocytopenia, acidosis, high
lactate or hyperbilirubinemia.
• Children: suspected or proven
infection and ≥2 SIRS criteria, of
which one must be abnormal
temperature or white blood cell
count
Sepsis
11. • Adults: persisting hypotension despite
volume resuscitation, requiring
vasopressors to maintain MAP ≥65
mmHg and serum lactate level < 2
mmol/L
• Children: any hypotension (SBP <5th
centile or >2 SD below normal for age) or
2- 3 of the following: altered mental state;
bradycardia or tachycardia (HR <90 bpm
or >160 bpm in infants and HR <70 bpm
or >150 bpm in children); prolonged
capillary refill (>2 sec) or warm
vasodilation with bounding pulses;
tachypnea; mottled skin or petechial or
purpuric rash; increased lactate; oliguria;
hyperthermia or hypothermia
Septic
Shock
18. Symptomatic patients (at home):
Vitamin C 500 mg BID and Quercetin 250-500 mg
BID
Zinc 75-100 mg/day
Melatonin 6-12 mg at night (the optimal dose is
unknown)
Vitamin D3 1000-4000 u/day
Optional: ASA (aspirin) 81 -325 mg/day
Optional: Hydroxychloroquine 400mg BID day 1
followed by 200mg BID for 4 days
Optional: In highly symptomatic patients,
monitoring with home pulse oximetry is
recommended
19. Mildly Symptomatic patients:
Vitamin C 500mg q 6 hourly and Quercetin 250-500
mg BID (if available)
Zinc 75-100 mg/day
Melatonin 6-12 mg at night (the optimal dose is
unknown)
Vitamin D3 1000-4000 u/day
Enoxaparin 60 mg daily
Methylprednisolone 40 mg daily; increase to 40mg q
12 hourly in patients with progressive symptoms and
increasing CRP
Famotidine 40mg daily (20mg in renal impairment)
20. Cont…
Optional: Hydroxychloroquine 400mg BID day 1
followed by 200mg BID for 4 days
Optional: Remdesivir, if available
Nasal cannula 2L /min if required (max 4 L/min;
consider early t/f to ICU for escalation of care).
Avoid Nebulization and Respiratory treatments. Use
“Spinhaler” or Metered Dose Inhaler and spacer if
required.
Avoid non-invasive ventilation
T/f EARLY to the ICU for increasing respiratory
signs/symptoms and arterial desaturation.
21. Respiratory symptoms (SOB; hypoxia- requiring
N/C ≥ 4 L min: admit to ICU):
Essential Treatment (dampening the STORM)
1. Methylprednisolone 80 mg loading dose then
40mg q 12 hourly for at least 7 days and until
transferred out of ICU. In patients with an
increasing CRP or worsening clinical status
increase the dose to 80mg q 12 hourly, then
titrate down as appropriate.
2. Ascorbic acid (Vitamin C) 3g IV 6 hourly for
at least 7 days and/or until transferred out of
ICU.
22. 3. Full anticoagulation:
Unless contraindicated we suggest FULL
anticoagulation (on admission to the ICU) with
enoxaparin, i.e 1 mg/ kg s/c q 12 hourly .
Heparin is suggested with CrCl (creatinine
clearance)
< 15 ml/min.
Alternative approach: Half-dose rTPA
(alteplase): 25mg of tPA (tissue plasminogen
activator) over 2 hours followed by a 25mg tPA
infusion administered over the subsequent 22
hours, with a dose not to exceed 0.9 mg/kg
followed by full anticoagulation.
23. Additional Treatment Components
(the Full Monty)
4. Melatonin 6-12 mg at night (the optimal dose is
unknown).
5. Famotidine 40mg daily (20mg in renal
impairment)
6. Vitamin D 400u PO daily
7. Magnesium: 2 g stat IV. Keep Mg between 2.0
and 2.4 mmol/l.
8. Optional: Azithromycin 500 mg day 1 then 250
mg for 4 days (has immunomodulating
properties including downregulating IL-6; in
addition, Rx of concomitant bacterial
pneumonia).
24. 9. Optional: Atorvastatin 40-80 mg/day. Of
theoretical but unproven benefit.
Statins – it reduce mortality in the hyper-
inflammatory ARDS phenotype.
10. Broad-spectrum antibiotics
If superadded bacterial pneumonia is
suspected based on procalcitonin levels and
resp.
25. Cont…
11. Maintain EUVOLEMIA
Rehydration with 500 ml boluses of Lactate
Ringers may be warranted, ideally guided by
noninvasive hemodynamic monitoring.
Diuretics should be avoided unless the patient
has obvious intravascular volume overload.
Avoid hypovolemia.
12. Early norepinephrine for hypotension.
26. Cont…
13. Escalation of respiratory support (steps);
Accept “permissive hypoxemia” (keep O2
Saturation > 84%);
Follow venous lactate and Central Venous O2
saturations in patents with low arterial O2
saturations
N/C 1-6 L/min
High Flow Nasal cannula (HFNC) up to 60-80
L/min
Trial of inhaled Flolan (epoprostenol)
Attempt proning (cooperative repositioning-
27. Intubation
Crash/emergency intubations should be
avoided.
Volume protective ventilation; Lowest driving
pressure and lowest PEEP as possible. Keep
driving pressures < 15 cmH2O.
Moderate sedation to prevent self-extubation
Trial of inhaled Flolan (epoprostenol)
Prone positioning.
28. There is however, no evidence to
support this fear.
High flow nasal cannula is a better
option for the patient and the health care
system than intubation and mechanical
ventilation.
CPAP/BiPAP may be used in select
patients, notably those with COPD
exacerbation or heart failure.
29. 14.Salvage Treatments
Plasma exchange
ECMO (extracorporeal membrane
oxygenation)
High dose corticosteroids; 120mg
methylprednisolone q 6-8 hourly
Siltuximab and Tocilizumab (IL-6 inhibitors)
15. Treatment of Macrophage Activation
Syndrome (MAS)
A ferritin > 4400 ng/ml is considered diagnostic
of MAS.
30. “High dose corticosteroids.”
Methylprednisolone 120 mg q 6-8 hourly for at
least 3 days, then wean according to Ferritin,
CRP, AST/ALT .
Ferritin should decrease by at least 15% before
weaning corticosteroids.
Consider plasma exchange.
Anakinra (competitively inhibits IL-1 binding to
the interleukin-1 type I receptor) can be
considered in treatment failures.
31. 16. Monitoring
Daily: PCT (procalcitonin), CRP,(C-reactive
protein ) IL-6, BNP(brain natriuretic peptide),
Troponins, Ferritin, Neutrophil-Lymphocyte
ratio, D-dimer and IL-6 and Ferritin track
disease severity closely (although ferritin tends
to lag behind CRP).
Thromboelastogram (TEG) on admission and
repeated as indicated.
Patients receiving IV vitamin C.
32. 17. Post ICU management
a. Enoxaparin 40-60 mg s/c daily
b. Methylprednisone 40 mg day, the wean slowly
c. Vitamin C 500 mg PO BID
d. Melatonin 3-6 mg at night
