Improving the early identification of COVID-19 pneumonia: a narrative review

Abstract

Delayed presentation of COVID-19 pneumonia increases the risk of mortality and need for high-intensity healthcare. Conversely, early identification of COVID-19 pneumonia grants an opportunity to intervene early and thus prevent more complicated, protracted and less successful hospital admissions. To improve the earlier detection of COVID-19 pneumonia in the community we provide a narrative review of current evidence examining the clinical parameters associated with early disease progression. Through an evolving literature review, we examined: the symptoms that may suggest COVID-19 progression; the timing of deterioration; the utility of basic observations, clinical examination and chest X-ray; the value of postexertion oxygen saturations; and the use of CRP to monitor disease progression. We go on to discuss the challenges in monitoring the COVID-19 patient in the community and discuss thresholds for further assessment. Confusion, persistent fever and shortness of breath were identified as worrying symptoms suggestive of COVID-19 disease progression necessitating urgent clinical contact. Importantly, a significant proportion of COVID-19 pneumonia patients appear not to suffer dyspnoea despite severe disease. Patients with this asymptomatic hypoxia seem to have a poorer prognosis. Such patients may present with other signs of hypoxia: severe fatigue, exertional fatigue and/or altered mental status. We found duration of symptoms to be largely unhelpful in determining risk, with evidence of deterioration at any point in the disease. Basic clinical parameters (pulse, respiratory rate, blood pressure, temperature and oxygen saturations (SpO2)) are likely of high value in detecting the deteriorating community COVID-19 patient and/or COVID-19 mimickers/complications (eg, sepsis, bacterial pneumonia and pulmonary embolism). Of these, SpO2 carried the greatest utility in detecting COVID-19 progression. CRP is an early biochemical parameter predictive of disease progression and used appropriately is likely to contribute to the early identification of COVID-19 pneumonia. Identifying progressive COVID-19 in the community is feasible using basic clinical questions and measurements. As such, if we are to limit the mortality, morbidity and the need for complicated, protracted admissions, monitoring community COVID-19 cases for signs of deterioration to facilitate early intervention is a viable strategy.

Performance of the ROX index in predicting high flow nasal cannula failure in COVID-19 patients: a systematic review and meta-analysis

“…We are also aware that the absence of standardised reporting protocols for HFNC use can lead to sources of bias that are difficult to account for based on the extant literature. For example, few studies report at which point from onset of COVID-19 illness that the patient presented (which is potentially important as patient presenting very late or very early could have a different disease course [ 51 – 53 ]). Other sources of heterogeneity include the definition of HFNC failure, where some studies reported a composite outcome including mortality, on top of the need for intubation or mechanical ventilation.…”

Differences in acoustic features of cough by pneumonia severity in patients with COVID-19: a cross-sectional study

“…However, although risk stratification protocols have been developed [ 11 ], potential diagnostic and prognostic tools are mostly based on relatively expensive and in many scenarios, difficult-to-access imaging methods (radiography, ultrasound, computed tomography (CT)) [ 12 , 13 ]. There is a clinical need for a simpler and more widely available prognostic tool that would enable healthcare providers to identify patients who have developed or are at risk of developing a severe disease, thereby facilitating triaging of patients and early intervention even at a patient's home or primary care centres [ 14 – 16 ].…”

Factors Associated with Pneumonia in Patients Hospitalized with COVID-19 and the Role of Vaccination

“…Numerous articles have attempted to summarize and delineate symptoms according to the severity of the SARS-CoV-2 disease [ 4 , 5 , 6 ]. Most COVID-19 patients present a self-limiting viral infection with cough, sore throat, headache, myalgia, fever, and other cold or flu symptoms.…”