Department of Acute Internal Medicine, Gibraltar Health Authority, Gibraltar, Gibraltar
Department of Infection, Antimicrobial Resistance and Deterioration, NHS England, Redditch, Worcestershire, UK.
BMJ Open Respir Res. 2021 Nov;8(1). doi: 10.1136/bmjresp-2021-000911.
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 (SpO)) 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, SpO 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.
新冠肺炎肺炎的延迟表现增加了死亡率和需要高强度医疗保健的风险。相反，早期识别新冠肺炎肺炎为早期干预提供了机会，从而防止更复杂、更持久和成功率更低的住院治疗。为了提高社区中新冠肺炎肺炎的早期检测率，我们提供了一份关于当前研究的叙述性综述，该研究检查了与疾病早期进展相关的临床参数。通过不断发展的文献综述，我们研究了：可能提示新冠肺炎进展的症状；病情恶化的时间；基本观察、临床检查和胸部 X 光的效用；运动后血氧饱和度的价值；以及使用 CRP 来监测疾病进展。我们接着讨论了在社区中监测新冠肺炎患者的挑战，并讨论了进一步评估的阈值。我们发现，持续发热、呼吸困难和呼吸急促是新冠肺炎疾病进展的令人担忧的症状，需要紧急临床联系。重要的是，尽管病情严重，但相当一部分新冠肺炎肺炎患者似乎没有出现呼吸困难。这些无症状缺氧的患者似乎预后较差。这些患者可能表现出其他缺氧迹象：严重疲劳、运动疲劳和/或精神状态改变。我们发现，症状持续时间在很大程度上无助于确定风险，疾病的任何阶段都有恶化的证据。基本临床参数（脉搏、呼吸频率、血压、体温和血氧饱和度（SpO））可能在检测病情恶化的社区新冠肺炎患者和/或新冠肺炎模拟症/并发症（如败血症、细菌性肺炎和肺栓塞）方面具有很高的价值。在这些参数中，SpO 在检测新冠肺炎进展方面具有最大的效用。CRP 是一种早期的生化参数，可预测疾病的进展，如合理使用，可能有助于早期识别新冠肺炎肺炎。使用基本的临床问题和测量方法，在社区中识别进行性新冠肺炎是可行的。因此，如果我们要限制死亡率、发病率和对复杂、持久住院治疗的需求，那么监测社区中新冠肺炎病例以发现病情恶化迹象，从而促进早期干预是一种可行的策略。
