Dr Jiunn Liang Tan (Malaysia) responds:
Dr Jiunn Liang Tan (Malaysia) responds:
Dr Kuo-Chin Kao (Taiwan) responds:
Dr Dinesh Dassanayake (Sri Lanka) responds:
Dr Jiunn Liang Tan (Malaysia) responds:
Dr Kuo-Chin Kao (Taiwan) responds:
Dr Jiunn Liang Tan (Malaysia) responds:
COVID patient tend to present with dry cough, lethargy and shortness of breath. Anosmia also could be a common presentation in our cohort.
We also noticed the COVID pneumonia patient can deteriorate very quickly. Hence, we tend to monitor more closely when the patient is at day 6 – 8 of illness. Even a slight dropped of SPO2 from 99% to 96% could be an early clue to possible rapid deterioration.
The deterioration mainly due to cytokine storm – immunological response towards the viraemia.
Dr Kuo-Chin Kao (Taiwan) responds:
In addition to TOCC history, COVID-19 patients tend to suffered from shortness of breath, dry cough, and anosmia.
Dr Jiunn Liang Tan (Malaysia) responds:
We give our patient 3 months follow up plan to monitor their lung function and relevant blood test. We do not monitor for potential reinfection at the moment.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not have monitor for potential reinfection post COVID-19 infection in our hospital.
Dr Jiunn Liang Tan (Malaysia) responds:
No. There is not enough evidence to suggest treatment for asymptomatic COVID19 patient. The risk has outweighed the benefit of treating this group of patient. Hydroxychloroquine has not proven to be the effective treatment for COVID19 pneumonia. We advocate strict quarantine of these group of patient and closely monitor them esp when it is Day 6 – 8 of illness.
Dr Kuo-Chin Kao (Taiwan) responds:
I do not advise HCQ for asymptomatic patients for prevention in terms of the potential side effects.
Dr Jiunn Liang Tan (Malaysia) responds:
CT scan in severe COVID19 patient could be very heterogenous. The common features tend to be the peripheral ground glass changes.
Dr Kuo-Chin Kao (Taiwan) responds:
I do not think the CT features of severe COVID-19 resemble that of rapidly progressive ILD. The CT features would be heterogenous such as GGO and consolidation.
Dr Jiunn Liang Tan (Malaysia) responds:
We have no experience in using CYTOSORB. There's one patient that we planned to used but he sort of improved after Tocilizumab. Hence, we have not tried it. There's report from UK that this therapy may works.
YES. You can use HFNC or NIV. I think somehow by using HFNC together with Tocilizumab/antiviral, we can avoid mechanical ventilation in some selected patients. The only problem with HFNC & NIV is both device is consider aerosol generating device, if we are using them, these patient need to be in negative pressure room.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not have the experience of CYTOKINE FILTERS
Dr Jiunn Liang Tan (Malaysia) responds:
Depend on the severity. We advocate treatment for patient with moderate – severe pneumonia with exception of elderly patient or those with comorbidities.
Dr Kuo-Chin Kao (Taiwan) responds:
Regarding the COVID-19 caused by SARS-CoV-2, no therapies have been shown effective to date.
1. JAMA. 2020 Apr 13. doi: 10.1001/jama.2020.6019. [Epub ahead of print
Dr Jiunn Liang Tan (Malaysia) responds:
Depend on the test kit that are used. Different test kit detecting different part of the virus. Need to look at the manual for the test kit.
Dr Kuo-Chin Kao (Taiwan) responds:
In Taiwan, the RT-PCR test is the golden standard diagnosis of COVID-19. Rapid test or antibody test were not available in practice at this moment.
Dr Jiunn Liang Tan (Malaysia) responds:
Malignancy is definitely one of the risk factor for developing any lung infection especially among those on chemotherapy. When the immune system are most vulnerable.
For those on molecular targeted therapy/ immune check point inhibitor, the risk of COVID19 infection is the same as any patient with chronic lung disease.
The most important things are the history of contact with COVID patients or recent travelling to overseas. CT scan for COVID can mimic a lot of condition. Hence, it's not specific. If there's a suspicion, we would perform the RT-PCR testing for COVID.
Dr Kuo-Chin Kao (Taiwan) responds:
I do not have the experience on this issue and without any comment.
Dr Jiunn Liang Tan (Malaysia) responds:
No. Patient should be isolated/quarantine.
Dr Kuo-Chin Kao (Taiwan) responds:
No. Treat or not depends on the weather the symptom is related virus infection.
Dr Jiunn Liang Tan (Malaysia) responds:
Surgical mask alone is not enough to protect the chest physician.
We suggest social distancing at consultation room. If there's close handling of patient, the HCW should wear face-shield together with the surgical mask and apron as well as surgical glove. Proper hand hygiene should be practise.
If there's aerosol generating procedure i.e Nebuliser, performing PEFR, HCW should wear all the above plus head cover, shoe cover and N95 mask.
Dr Kuo-Chin Kao (Taiwan) responds:
In chest clinic, we suggest the PPE would be N-95 mask, face-shield, head cover, contagion gown and surgical glove.
Dr Jiunn Liang Tan (Malaysia) responds:
No issue with the use of omeprazole among our COVID patients.
Dr Kuo-Chin Kao (Taiwan) responds:
I have no comment on the use of PPI in COVID-19 patients.
Dr Jiunn Liang Tan (Malaysia) responds:
All of us are still learning to treat this new disease.
Dr Kuo-Chin Kao (Taiwan) responds:
I think so. However, all of us are still learning to manage and treat this novel disease.
Dr Jiunn Liang Tan (Malaysia) responds:
No proven therapy at the moment. ICU care mainly.
We use IV Tocilizumab if there's evidence of cytokine storm. Our personal experience with Tocilizumab is quite promising.
We have tried Kaletra & Interferon, but the outcome are not encouraging.
Dr Kuo-Chin Kao (Taiwan) responds:
For the severe pneumonia caused by the COVID-19, the major treatment is to correct hypoxemia by oxygen therapy. The most two important points are to closed monitoring the response of oxygen therapy and to set a threshold to determine the timing of intubation if the condition deteriorated. In order to prevent the complications related to intubation in these isolated patients, early and a planned intubation are necessary.
(No reponse yet)
Dr Jiunn Liang Tan (Malaysia) responds:
We think that human is one of the reservoir for SARS-CoV2.
Possible. Need more study on this.
From WHO: At present there is no evidence of severe adverse events, acute health care utilization, long-term survival, or quality of life in patients with COVID-19, as a result of the use of NSAIDs. www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19
Need more study to determine this.
Dr Kuo-Chin Kao (Taiwan) responds:
Dr Jiunn Liang Tan (Malaysia) responds:
Looking at the situation, some said may be last until end of the year or 2021.
Dr Kuo-Chin Kao (Taiwan) responds:
I cannot forecast the time about the coronavirus issue ending. It might be different in the different countries or areas.
Dr Jiunn Liang Tan (Malaysia) responds:
All medical devices used on COVID patient need to be cleaned with alcohol based cleanser.
Dr Kuo-Chin Kao (Taiwan) responds:
All medical devices including stethoscope used on COVID patients need to be cleaned with alcohol based cleanser. At a special situation, we do not suggest using stethoscope to check the position of endotracheal tube when patient was intubated. We suggest using disposable etCO2 measure to confirm the ET tube which was located in the trachea not in esophagus.
Dr Jiunn Liang Tan (Malaysia) responds:
We think that used of low dose methylprednisolone mainly at the peak viremic phase to prevent cytokine storm. Use of steroid in ARDS have limited evidence. We do not use steroid in ARDS.
We do not have experience using convalescent plasma.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not suggest routinely use steroid for COVID-19 patients. We do not have experience of convalescent plasma in the treatment of COVID-19 patients.
Dr Dinesh Dassanayake (Sri Lanka) responds:
Steroids: There are no RCTin COVID .Previos studies on Viral pneumonias ithout ARDS has shown increased mortality and harmful effects.However recent case series and retrospective cohort analysis has shown reduced martality.Therefore some guidelines recomend using steroids for COVID with ARDS, and also for other compelling indications like asthma and COPD exacerbation.Steroids not recommended routinely. Convalacent plasma :No RCT but previos studies on viral pneumonia has shown reduced mortality.Case series in China has shown reduced viralload and increased neutralizing antibody levels.Therefore its not recommended routinely but compassionate use is permitted for severe ife threatning COVD.
Dr Jiunn Liang Tan (Malaysia) responds:
Rapid mass screening for detection of COVID19.
Dr Kuo-Chin Kao (Taiwan) responds:
The antigen rapid test kit could be used for rapid mass screening for detection of COVID19. However, the false negative result issue should be addressed carefully.
Dr Jiunn Liang Tan (Malaysia) responds:
erj.ersjournals.com/content/early/2020/03/17/13993003.00607-2020
journals.physiology.org/ajplung/The-Pathophysiology-of-CoV-2-COVID-19-and-SARS-Infection
Dr Kuo-Chin Kao (Taiwan) responds:
These two references well addressed the possible pathophysiology of COVID-19 pneumonia.
1. Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2
2. Gattinoni et al. Critical Care (2020) 24:154
Dr Jiunn Liang Tan (Malaysia) responds:
Similar to any patient with hypoxemic respiratory failure.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not suggest using NIV in hypoxemic respiratory failure in COVID-19 patients. Early intubation is preferred.
Dr Dinesh Dassanayake (Sri Lanka) responds:
NIV is an aerosol generating procedure and previos experience has shown increased viral transmission to health care workers.Studies in China has shown very high failure rate.Therefore most guidelines discourage use of NIV.Except when other resources are exhousted and HFNC are not available.If NIV is used it should be done with strict airbourn precautions and a dual limb circuit should be used with HEPA and viral filters.
Dr Jiunn Liang Tan (Malaysia) responds:
We prefer HFNC over early intubation. Those on HFNC in our cohort seems to be doing better than those intubated patient.
Dr Kuo-Chin Kao (Taiwan) responds:
In practically, HFNC might be better than early intubation. However, you should closed monitor the patient to avoid emergent intubation. Regarding the parameter or timing of early intubation, no response or mild deterioration to present treatment should be considered.
Dr Jiunn Liang Tan (Malaysia) responds:
Elevated D-dimer is link with severe COVID pneumonia and it's a prognostic indicator for mortality.
We used prophylactic anticoagulant in patient with risk factors to develop VTE.
Dr Kuo-Chin Kao (Taiwan) responds:
The hypoalbuminemia, hypocalcemia and elevated D-dimer are common complications in the critical ill patients. We do not suggest routinely use anticoagulant in COVID-19 critical ill patients.
Dr Jiunn Liang Tan (Malaysia) responds:
We are yet to know about this. Need to follow up with these patients to determine the progression.
Dr Kuo-Chin Kao (Taiwan) responds:
We are yet to observe about this phenomenon. Some patients may have post infection pulmonary fibrosis and it is possible to completely recovery later. We need more time to follow up these post COVID-19 infection patients.
Dr Jiunn Liang Tan (Malaysia) responds:
We have some patient with chronic respiratory disease but the numbers are small.
Dr Kuo-Chin Kao (Taiwan) responds:
Among our COVID-19 patients, most of patients were young age and very few patients with chronic respiratory disease.
Dr Jiunn Liang Tan (Malaysia) responds:
From our own centre experience, so far only one mortality among those 10 patients admitted. Those who survived are those who have received IV Tocilizumab at the appropriate timing. The one that died actually received IV Tocilizumab as well but was given too late.
Dr Kuo-Chin Kao (Taiwan) responds:
From the limited date from Taiwan CDC, the estimated mortality rate is about 25% inCOVID-19 patients with mechanical ventilation. According to the published articles from China, Italy, UK and USA, the mortality rates are very varied. One important factor related to mortality or survival is the capacity of critical care service.
Dr Jiunn Liang Tan (Malaysia) responds:
We are planning a study on this. At the moment, not enough evidence to make any recommendation.
Dr Kuo-Chin Kao (Taiwan) responds:
I do not suggest the prophylactic HCQ for anyone due to the potential side effects.
(No reponse yet)
Dr Jiunn Liang Tan (Malaysia) responds:
We do not use chloroquine. We used hydroxychloroquine to treat high risk patients that presented with mild symptoms. We do not prophylactically give HCQ to all patient.
Dr Kuo-Chin Kao (Taiwan) responds:
I do not suggest the prophylactic HCQ or chloroquine for anyone due to the potential side effects.
Dr Jiunn Liang Tan (Malaysia) responds:
We do not use azithromycin in our centre.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not use azithromycin only for COVID-19.
Dr Kuo-Chin Kao (Taiwan) responds:
Dr Kuo-Chin Kao (Taiwan) responds:
In Taiwan, all of the confirmed cases were isolated or treated in the standard negative pressure isolation rooms in hospitals rather than home. Until to April 23rd, totally 427 confirmed cased was reported and 253 cases were released from quarantine in Taiwan.
Dr Jiunn Liang Tan (Malaysia) responds:
We think that used of low dose methylprednisolone mainly at the peak viremic phase to prevent cytokine storm. Use of steroid in ARDS have limited evidence. We do not use steroid in ARDS.
Dr Kuo-Chin Kao (Taiwan) responds:
In general, we do not use steroid in COVID-19 patients except some underlying conditions need steroid such as asthma or COPD with AE.
Dr Dinesh Dassanayake (Sri Lanka) responds:
see section on steroids
Dr Jiunn Liang Tan (Malaysia) responds:
We have no experience in using convalescent plasma.
Dr Kuo-Chin Kao (Taiwan) responds:
We have no experience in using convalescent plasma to treat COVID-19 patients.
Dr Dinesh Dassanayake (Sri Lanka) responds:
see section on caonvalacent plasma
Dr Jiunn Liang Tan (Malaysia) responds:
Yes. They are quite sensitive. SARS-CoV2 can survive quite long on various surfaces.
Dr Kuo-Chin Kao (Taiwan) responds:
I have no idea about this question. Regarding the sensitivity of PCR test of COVID-19, many factors will affect the sensitivity such as site of specimen, technique of sampling, transportation of specimen, and timing from sampling to examination.
Dr Kuo-Chin Kao (Taiwan) responds:
In Taiwan, many COVID-19 patients were imported from USA, Europe and other countries. Most of these patients were students studied in USA and European countries.
Dr Jiunn Liang Tan (Malaysia) responds:
Yes
Dr Kuo-Chin Kao (Taiwan) responds:
Yes.
Dr Jiunn Liang Tan (Malaysia) responds:
We have no experience in this aspect. Anyway, guidelines do not recommend the use of one ventilator for multiple patients as every patient's condition is different and the stage of disease also varies.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not have the experience in ventilating 2 patients in one ventilator. We strongly suggest to avoid doing this.
Dr Jiunn Liang Tan (Malaysia) responds:
RT-PCR testing is quite sensitive. It's the method of acquiring the sample. If the nasal swab or oropharyngeal swab was performed incorrectly, RT-PCR testing would be negative.
The role of serology is yet to be determine as some recovered COVID patient still can be re-infected. Positive serology seems like not equivalent to acquired immunity.
Dr Kuo-Chin Kao (Taiwan) responds:
We do not have the exact data regarding the frequency of PCR negative conversion in the recovery stage of COVID-19 patients. However, some confirm COVID-19 patients will take a long time (up to 2 months) to obtain continuous 3 times (apart from 24 hours) negative PCR results from nasopharynx.
See also recording at www.youtube.com/watch?v=rii8b07ZPiM&feature=youtu.be.