Brescia_COVID_Respiratory_Severity_Scale_BCRSS_Algorithm_guideline v.1

Brescia-COVID Respiratory Severity Scale (BCRSS)/Algorithm is a step-wise approach to managing patients with confirmed/presumed COVID-19 pneumonia.

Maryam Razavi

maryam.razavi@cambio.se

@CambioCDS

To assess and provide treatment recommendations in patients with confirmed/presumed COVID-19 pneumonia.

Use to recommend increasing treatment recommendations, simplify the clinical summary of a patient’s status, compare patients to one another, monitor patients nearing a critical action point more closely, and trend patients’ levels over time. Use in patients who have COVID-19 pneumonia OR have had COVID-19 symptoms for ≥7 days AND are either PCR+ OR high clinical suspicion for COVID-19. IPrecondition: [Patient has COVID-19 pneumonia or COVID-19 symptoms for ≥7 days] AND [Patient is PCR+ OR high suspicion for COVID-19/PCR pending]. Testing Criteria: - Patient wheezing OR unable to speak in full sentences while at rest/with minimal effort: yes=1, No=0. - Respiratory rate >22: yes=1, No=0. - PaO2 <65 mmHg or SpO2 <90%: yes=1, No=0. - Repeat CXR is significantly worsening: yes=1, No=0. When >2 criteria are selected, the algorithm recommends escalating to non-invasive ventilation (NIV/CPAP/BiPAP) or high-flow nasal cannula (HFNC) and then reassessing patient criteria. Does the patient still have >2 criteria despite NIV/HFNC?: No, Yes. Intubation recommended for worsening symptoms despite NIV/HFNC. With the patient intubated: Is the intubated patient on CMV? : No, Yes. PaO2/FiO2 <150 mmHg : No, Yes. Patient on neuromuscular blockade (NMBA): No, Yes. Patient prone or on ECMO: No, Yes. Interpretation: The formula of testing criteria score: Additional of selected parameters. Testing criteria score equal to 0= Level 0, Management: Keep patient monitored with pulse oximetry and clinical evaluation, Medications: Lopinavir/ritonavir. Testing criteria score equal 1=Level 1, Management: Provide supplemental O2. Keep the patient monitored with pulse oximetry and clinical evaluation, Medications: Lopinavir/ritonavir. Testing criteria score equal to 2= Level 2, Management: Perform CXR and ABG. Provide supplemental O2. Keep the patient monitored with pulse oximetry and clinical evaluation, Medications: Lopinavir/ritonavir. Consider dexamethasone, Consider age/comorbidities, cognitive decline. Testing criteria score equal to 3= Level 3, Management: Trial of non-invasive ventilation (CPAP/BiPAP), or high-flow nasal cannula (HFNC) recommended. If the above clinical criteria worsening or the patient clinically worsening despite this trial, intubation recommended. Otherwise, perform CXR every 2 days and ABG twice a day, Medications: Lopinavir/ritonavir. Consider dexamethasone and consider starting tocilizumab. Consider age/comorbidities, cognitive decline. Inclusion criteria. When Testing criteria score >2 and Does the patient still have >2 criteria despite NIV/HFNC? =No: Re-select the number of criteria present and follow management. When Testing criteria score >2, and Does the patient still have >2 criteria despite NIV/HFNC? Yes: - Intubation recommended for worsening symptoms despite NIV/HFNC. With the patient intubated: Is the intubated patient on CMV?: No= Level 4, Management: Follow ICU protocols; use local ventilator weaning protocol, Medications: Remdesivir (if not available, lopinavir/ritonavir) PLUS considering dexamethasone and tocilizumab, Consider age/comorbidities, cognitive decline, Inclusion criteria. Is the intubated patient on CMV? Yes and PaO2/FiO2 <150 mmHg: No= Level 5, Management: Try to minimize sedation (RASS -1 to 0). Perform SBT daily, Medications: Remdesivir (if not available, lopinavir/ritonavir) PLUS considering dexamethasone and tocilizumab, Consider age/comorbidities, cognitive decline, Inclusion criteria. Does the patient still have >2 criteria despite NIV/HFNC? Yes and Is the intubated patient on CMV? Yes and PaO2/FiO2 <150 mmHg: Yes and Patient on neuromuscular blockade (NMBA): No= Level 6, Management: Try to minimize sedation (RASS -1 to 0), Medications: Remdesivir (if not available, lopinavir/ritonavir) PLUS considering dexamethasone and tocilizumab, consider age/comorbidities, cognitive decline, Inclusion criteria. Does the patient still have >2 criteria despite NIV/HFNC?: Yes and Is the intubated patient on CMV?: Yes and PaO2/FiO2 <150 mmHg: Yes and Patient on neuromuscular blockade (NMBA): Yes, Patient prone or on ECMO: No= Level 7, Management: Perform best PEEP and Compliance calculation. Try to suspend NMBA. Optimize volume status, Medications: Remdesivir (if not available, lopinavir/ritonavir) PLUS considering dexamethasone and tocilizumab, consider age/comorbidities, cognitive decline, Inclusion criteria. Does the patient still have >2 criteria despite NIV/HFNC?: Yes and Is the intubated patient on CMV?: Yes and PaO2/FiO2 <150 mmHg: Yes and Patient on neuromuscular blockade (NMBA): Yes, Patient prone or on ECMO: Yes= Level 8, Management: Extreme level of medical complexity given failing other management options; defer to clinician expertise, Medications: Remdesivir (if not available, lopinavir/ritonavir) PLUS considering dexamethasone and tocilizumab, consider age/comorbidities, cognitive decline, Inclusion criteria. Inclusion criteria for tocilizumab: End of the initial phase of high viral load of COVID-19 (e.g. apyretic from >72h and/or elapsed ≥7 days after the onset of symptoms). Worsening of respiratory exchanges, such as to require non-invasive or invasive support from ventilation (Level ≥3). High levels of IL-6 (>40 pg/mL); alternatively, high levels of d-dimer, CRP, ferritin, and/or fibrinogen progressively increasing. Use with caution; this is being used in Italy for assessment, trending, and treatment recommendations and it was launched during the COVID-19 crisis. Not externally validated.

1. Italian Society of Infectious and Tropical Diseases (SIMIT). Guidelines on therapeutic and supportive management for patients with COVID-19 coronavirus infection. 2020.

OBSERVATION.brescia_covid_respiratory_severity_scale_bcrss_algorithm.v0, EVALUATION.brescia_covid_respiratory_severity_scale_bcrss_algorithm.v0