The following are key points to remember from a clinical practice approach to severe coronavirus disease 2019 (COVID-19):

1. The most common initial symptoms of COVID-19 are fever, cough, fatigue, headache, myalgias, and diarrhea.
2. Patients with severe COVID-19 may become critically ill with acute respiratory distress syndrome that typically begins approximately 1 week after the onset of symptoms. Dyspnea is the most common symptom of severe disease and is often accompanied by hypoxemia.
3. Deciding when a patient with severe COVID-19 should receive endotracheal intubation is an essential component of care. Clinicians must weigh the risks of premature intubation against the risk of sudden respiratory arrest with a chaotic emergency intubation, which exposes staff to a greater risk of infection.
4. Possible clinical indications for endotracheal intubation:
   • Impending airway obstruction
   • Signs of unsustainable work of breathing
   • Refractory hypoxemia
   • Hypercapnia or academia
   • Encephalopathy or inadequate airway protection
5. Additional considerations for endotracheal intubation:
   • Does illness trajectory predict deterioration?
   • Are difficulties in endotracheal intubation anticipated?
   • Is there hemodynamic instability?
   • Will intubating now improve the safety of a planned procedure or transportation?
   • Will intubating now improve infection control and staff safety?
6. After intubation, patients should receive lung-protective ventilation with plateau pressure ≤30 cm of water and with tidal volumes based on the patient’s height.
7. Prone positioning is a potential treatment strategy for refractory hypoxemia.
8. Thrombosis and renal failure are well-recognized complications of severe COVID-19.
9. Data are needed from randomized trials to inform the benefits and risks of antiviral or immunomodulatory therapies for severe COVID-19.
10. Preliminary data from a randomized, placebo-controlled trial involving patients with severe COVID-19 suggest that the investigational antiviral remdesivir shortens time to recovery.
11. The presence of unexplained hemodynamic instability should prompt consideration of myocardial ischemia, myocarditis, or pulmonary embolism.
12. Finally, during the COVID-19 pandemic, an overwhelming surge of patients presenting to a hospital may temporarily require the rationing of health care resources. Local guidelines and medical ethics consultation can help clinicians navigate these difficult decisions with patients and their families.

Clinical Topics: COVID-19 Hub, Heart Failure and Cardiomyopathies, Prevention

Keywords: Antiviral Agents, Cough, Coronavirus, COVID-19, Critical Illness, Dyspnea, Hypercapnia, Immunomodulation, Intubation, Intratracheal, Myalgia, Myocardial Ischemia, Myocarditis, Pandemics, Primary Prevention, remdesivir, Renal Insufficiency, Respiratory Distress Syndrome, Risk Assessment, severe acute respiratory syndrome coronavirus 2, Thrombosis

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