The Ministry of Health has published a document which explains how to treat COVID-19 at home, and when to call for help if your health deteriorates. The document is called “Home management of patients with SARS-CoV-2 infection”: it was published above all to give precise indications to family doctors. The latest official guidelines, in fact, had been released in the first months of the emergency, in March. Therapies have since changed and new protocols have been studied, nationally and internationally.
In mid-November, for example, the Medical Orders of all the provinces of Lombardy have sent a circular which contains a series of indications for all family doctors. The Ministry of Health intervened with a definitive document that outlines a single strategy, with prescriptions that must be followed throughout Italy.
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The clinical course
The first part of the document shows the three stages of the clinical course. In the first stage of the disease, the most common symptoms are general malaise, fever and dry cough. Those who do not improve and enter the second phase face more severe symptoms, such as interstitial pneumonia, very often bilateral. Attention should also be paid to mild symptoms. The document of the ministry, in fact, explains that in this phase of COVID-19 the phenomenon of the so-called “silent hypoxemia” can occur, that is a low oxygenation of the blood and injuries to the lungs, but in the absence of respiratory crises.
The third and final phase is the most dangerous, with the lungs now compromised and the possibility of having thrombosis of the small vessels. “This very serious clinical picture leads to ARDS (Acute Respiratory Distress Syndrome) severe and in some cases to the triggering of disseminated intravascular coagulation phenomena “, therefore to the blockage of small blood vessels throughout the body.
The ministry explains that the data collected so far have shown an association between the disease in the most severe phase and conditions such as “advanced age, especially over 70 years, the number and type of associated diseases, male sex and latency between the onset of symptoms and the first medical evaluation ». So it is important to be seen by a doctor quickly, shortly after symptoms appear. People with high blood pressure, atrial fibrillation, heart failure, diabetes mellitus, kidney failure and coronary artery disease are most at risk.
The home visit to a Covid-19 patient in Florence (Gianluca Panella / Getty Images)
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The importance of the oximeter
Patients with mild symptoms should in any case be visited by the family doctor or by the USCA, the Special Continuity Care Units, i.e. teams of doctors and nurses who have the task of assisting the sick at home. The progression of the disease, and any risks of worsening, can also be monitored independently after the first visit to the doctor. The most important parameter to check is the oxygen saturation in the blood. It can be measured thanks to a oximeter, an instrument that works in infrared and shows the percentage of oxygen in a person’s blood.
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In healthy adult non-smoking patients, saturation greater than 95 percent is considered normal. “Patients with Covid-19 at greatest risk of mortality are those who present with lower levels of blood oxygenation”, the document reads. “On the basis of the analysis of the scientific literature available to date and on the basis of the technical characteristics of the pulse oximeters available on the market for out-of-hospital use, it is believed to consider 92 percent of patients as a safety threshold for a COVID-19 patient oxygen saturation (SpO2) in ambient air ».
To assess conditions even more precisely, the oximeter can also be used after two simple stress tests. They are called “walk test” and “chair test”. The walk test consists of walking for up to six minutes along a 30-meter path while monitoring oxygen saturation.
The chair test, on the other hand, consists in the use of a chair without armrests, about 45 centimeters high, leaning against the wall: the patient, without the help of the hands and arms, with the legs open at the height of the hips, must perform as many repetitions in one minute by standing up and sitting down with legs bent at 90 degrees, monitoring oxygen saturation.
If the conditions worsen, so if the percentage of oxygen in the blood drops, the family doctor must consider a possible hospitalization. In the ministry document there is a diagram that explains when the 112 intervention is needed.
The scheme published in the document of the Ministry of Health
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Which drugs to use and which not
The therapy to be followed to treat patients with mild symptoms is very precise. The document lists all the actions to be followed to ensure correct patient management by the doctor (as always, do-it-yourself solutions must be avoided).
It starts with “watchful waiting” and “periodic measurement of oxygen saturation”. The next step is to use paracetamol, followed by appropriate hydration and nutrition. Normal treatments for chronic diseases should not be discontinued. Corticosteroid drugs, ie cortisone, should not be used regularly. The use of cortisone at home can be considered only in those patients “whose clinical picture does not improve within 72 hours, in the presence of a worsening of parameters”.
Heparin should also not be used, indicated only in subjects immobilized for infection. No antibiotics: their possible use is to be reserved only in the presence of persistent fever for over 72 hours.
As already shown by clinical studies, hydroxychloroquine is not effective and therefore should not be administered. The last recommendation warns not to administer drugs by aerosol if the patient is in isolation with other cohabitants, because it would increase the risk of virus circulation. The ministry also clarifies that there are no studies demonstrating the effectiveness of vitamins and food supplements against COVID-19.
The really useful drug for home care, therefore, is paracetamol. Alternatively, again according to the indications of the ministry, NSAID drugs, that is non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen, can also be used. These drugs are only used in case of fever, joint or muscle pain (unless there is a clear contraindication to use). “Other symptomatic drugs can be used on clinical judgment,” says the ministry. Paracetamol or NSAIDs can be used in case of fever or joint or muscle pain (unless there is a clear contraindication to use).
Managing the sick correctly in their homes is also important to avoid unnecessary hospitalization and therefore overcrowding in hospitals, especially in the emergency department. “Even on the occasion of this second pandemic wave, there is a need to rationalize resources in order to guarantee the right assistance to each individual citizen in a manner commensurate with the severity of the clinical picture”, explains the ministry. “A correct management of the case right from the diagnosis allows to implement a flow that has the dual purpose of making the patient safe and not crowding hospitals and especially emergency rooms in an unjustified manner”.
As we said, the indications contained in the ministry document are aimed at family doctors who are in charge of patients with SARS-CoV-2 infection and are not intended as instructions that patients can apply independently. If in doubt, it is always good to refer to your doctor.
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