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Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)

Chunxue Bai, Sanjay H. Chotirmall, Jordi Rello, George A. Alba, Leo C. Ginns, Jerry A. Krishnan, Robert Rogers, Elisabeth Bendstrup, Pierre-Regis Burgel, James D. Chalmers, Abigail Chua, Kristina A. Crothers, Abhijit Duggal, Yeon Wook Kim, John G. Laffey, Carlos M. Luna, Michael S. Niederman, Ganesh Raghu, Julio A. Ramirez, Jordi Riera, Oriol Roca, Maximiliano Tamae-Kakazu, Antoni Torres, Richard R. Watkins, Miriam Barrecheguren, Mirko Belliato, Hassan A. Chami, Rongchang Chen, Gustavo A. Cortes-Puentes, Charles Delacruz, Margaret M. Hayes, Leo M.A. Heunks, Steven R. Holets, Catherine L. Hough, Sugeet Jagpal, Kyeongman Jeon, Takeshi Johkoh, May M. Lee, Janice Liebler, Gerry N. McElvaney, Ari Moskowitz, Richard A. Oeckler, Iñigo Ojanguren, Anthony O'Regan, Mathias W. Pletz, Chin Kook Rhee, Marcus J. Schultz, Enrico Storti, Charlie Strange, Carey C. Thomson, Francesca J. Torriani, Xun Wang, Wim Wuyts, Tao Xu, Dawei Yang, Ziqiang Zhang, Kevin C. Wilson
European Respiratory Review 2020 29: 200287; DOI: 10.1183/16000617.0287-2020
Chunxue Bai
1Dept of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China
2Shanghai Respiratory Research Institution, Shanghai, China
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Sanjay H. Chotirmall
3Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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  • ORCID record for Sanjay H. Chotirmall
Jordi Rello
4Vall d'Hebron Research Institute, Barcelona, Spain
5Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
6CHU Nîmes, Nîmes, France
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George A. Alba
7Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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  • ORCID record for George A. Alba
Leo C. Ginns
7Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Jerry A. Krishnan
8Dept of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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Robert Rogers
7Division of Pulmonary and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Elisabeth Bendstrup
9Center for Rare Lung Diseases, Dept of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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  • ORCID record for Elisabeth Bendstrup
Pierre-Regis Burgel
10Dept of Respiratory Medicine, Cochin Hospital, Assistance Publique Hopîtaux de Paris, Université de Paris and Institut Cochin, Inserm U1016, Paris, France
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James D. Chalmers
11Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Abigail Chua
12Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, Stony Brook University, Stony Brook, NY, USA
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Kristina A. Crothers
13Dept of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle WA, USA
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Abhijit Duggal
14Dept of Critical Care, Cleveland Clinic, Cleveland OH, USA
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Yeon Wook Kim
15Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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  • ORCID record for Yeon Wook Kim
John G. Laffey
16Dept of Anesthesia and Intensive Care Medicine, Galway University Hospitals, National University of Ireland, Galway, Ireland
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Carlos M. Luna
17Dept of Medicine, Pulmonary Diseases Division, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
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  • ORCID record for Carlos M. Luna
Michael S. Niederman
18Division of Pulmonary and Critical Care, Dept of Medicine, Weill Cornell Medicine, New York NY, USA
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Ganesh Raghu
19Dept of Medicine, University of Washington, Seattle WA, USA
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Julio A. Ramirez
20Division of Infectious Diseases, Dept of Medicine, University of Louisville, Louisville KY, USA
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Jordi Riera
4Vall d'Hebron Research Institute, Barcelona, Spain
5Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
21Critical Care Dept, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
22Dept de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
23CIBERESUCICOVID: Centro de Investigación en red de Enfermedades Respiratorias, Madrid, Spain
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Oriol Roca
4Vall d'Hebron Research Institute, Barcelona, Spain
5Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
21Critical Care Dept, Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
22Dept de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
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Maximiliano Tamae-Kakazu
24Division of Pulmonary, Critical Care, and Sleep Medicine, Spectrum Health-Michigan State University, Grand Rapids MI, USA
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Antoni Torres
5Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
23CIBERESUCICOVID: Centro de Investigación en red de Enfermedades Respiratorias, Madrid, Spain
25Pulmonology Dept, University of Barcelona Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
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Richard R. Watkins
26Dept of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
27Division of Infectious Diseases, Cleveland Clinic Akron General, Akron, OH, USA
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Miriam Barrecheguren
28Respiratory Dept, Vall d'Hebron University Hospital, Barcelona, Spain
29Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Madrid, Spain
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Mirko Belliato
30UOC Anestesia e Rianimazione 1, IRCCS Policlinico San Matteo, Pavia, Italy
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Hassan A. Chami
31Dept of Medicine, American University of Beirut, Beirut, Lebanon
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Rongchang Chen
32Dept of Pulmonary and Critical Care Medicine, Shenzhen Institute of Respiratory Disease, Shenzhen People's Hospital, First Affiliated Hospital of South University of Science and Technology of China, Shenzhen, China
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Gustavo A. Cortes-Puentes
33Dept of Pulmonary Medicine, Mayo Clinic, Rochester MN, USA
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Charles Delacruz
34Dept of Medicine, Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven CT, USA
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Margaret M. Hayes
35Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
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Leo M.A. Heunks
36Dept of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Steven R. Holets
33Dept of Pulmonary Medicine, Mayo Clinic, Rochester MN, USA
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Catherine L. Hough
37Division of Pulmonary and Critical Care, Dept of Medicine, Oregon Health Sciences University, Portland, OR, USA
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Sugeet Jagpal
38Dept of Medicine, Robert Wood Johnson University Hospital, New Brunswick NJ, USA
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Kyeongman Jeon
39Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Takeshi Johkoh
40Dept of Radiology, Kansai Rosai Hospital, Amagaski, Japan
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May M. Lee
41Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, University of Southern California, Los Angeles CA, USA
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Janice Liebler
41Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Internal Medicine, University of Southern California, Los Angeles CA, USA
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Gerry N. McElvaney
42Department of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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Ari Moskowitz
35Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston MA, USA
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Richard A. Oeckler
33Dept of Pulmonary Medicine, Mayo Clinic, Rochester MN, USA
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Iñigo Ojanguren
28Respiratory Dept, Vall d'Hebron University Hospital, Barcelona, Spain
29Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Madrid, Spain
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Anthony O'Regan
43Dept of Respiratory Medicine, Galway University Hospitals, National University of Ireland, Galway, Ireland
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Mathias W. Pletz
44Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
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Chin Kook Rhee
45Division of Pulmonary, Allergy and Critical Care Medicine, Dept of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Marcus J. Schultz
36Dept of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Enrico Storti
46Dept of Anesthesia and Critical Care, Ospedale Maggiore di Lodi, Lodi, Italy
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Charlie Strange
47Dept of Medicine, Medical University of South Carolina, Charleston SC, USA
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Carey C. Thomson
48Division of Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Cambridge MA, Harvard Medical School, Boston MA, USA
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Francesca J. Torriani
49Infection Prevention and Clinical Epidemiology Unit at UC San Diego Health, Division of Infectious Diseases and Global Public Health, Department of Medicine, UC San Diego, San Diego CA, USA
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Xun Wang
50Dept of Pulmonary and Critical Care Medicine, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
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Wim Wuyts
51Dept of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
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Tao Xu
52Dept of Pulmonary and Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Dawei Yang
1Dept of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China
2Shanghai Respiratory Research Institution, Shanghai, China
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Ziqiang Zhang
53Dept of Pulmonary and Critical Care Medicine, Tongji Hospital Tongji University, Shanghai, China
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Kevin C. Wilson
54Dept of Medicine, Boston University School of Medicine, Boston, MA, USA
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  • For correspondence: kwilson@thoracic.org
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  • FIGURE 1
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    FIGURE 1

    The Convergence of Opinion on Suggestions and Evidence process. PICO: Patient, Intervention, Comparator, Outcomes.

Tables

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  • TABLE 1

    Task Force suggestions and interpretations

    Task ForceInterpretation
    SuggestsThe Task Force believes that the benefits exceed the harms and the intervention should be used
    Makes no suggestion for or againstThe Task Force believes that the benefit–risk ratio is uncertain, more evidence is needed and, for now, clinical equipoise exists
    Suggests against/notThe Task Force believes that the harms may exceed the benefits and, therefore, the intervention should not be used except in the context of a clinical trial
  • TABLE 2

    Summary of Task Force suggestions#

    The Task Force made the following consensus suggestions
    For hospitalised patients with COVID-19 pneumonia who require supplemental oxygen but are not mechanically ventilated, the Task Force suggests remdesivir:
     86% suggest remdesivir, 11% make no suggestion for or against remdesivir, and 3% suggest not using remdesivir
    For hospitalised patients with COVID-19 pneumonia who are mechanically ventilated, the Task Force suggests remdesivir:
     77% suggest remdesivir, 16% make no suggestion for or against remdesivir, and 7% suggest not using remdesivir
    For hospitalised patients with COVID-19 pneumonia who require supplemental oxygen but are not mechanically ventilated, the Task Force suggests dexamethasone:
     84% suggest dexamethasone, 13% make no suggestion for or against dexamethasone, and 3% suggest not using dexamethasone
    For hospitalised patients with COVID-19 pneumonia who are mechanically ventilated, the Task Force suggests dexamethasone:
     96% suggest dexamethasone, 1% make no suggestion for or against dexamethasone, and 3% suggest not using dexamethasone
    For adults who were hospitalised with COVID-19 pneumonia and had confirmed venous thromboembolism, the Task Force suggests therapeutic anticoagulant therapy for 3 months to reduce the risk of recurrent venous thromboembolism:
     95% favour therapeutic anticoagulant therapy for 3 months, 1% favour therapeutic anticoagulant therapy for >3 months, and 4% make no suggestion for either approach
    For hospitalised patients with COVID-19 pneumonia who require supplemental oxygen but are not mechanically ventilated, the Task Force suggests not using HCQ except within a clinical trial:
     3% suggest HCQ, 9% make no suggestion for or against HCQ, and 88% suggest not using HCQ
    For hospitalised patients with COVID-19 pneumonia who are mechanically ventilated, the Task Force suggests not using HCQ except within a clinical trial:
     0% suggest HCQ, 9% make no suggestion for or against HCQ, and 91% suggest not using HCQ

    COVID-19: coronavirus disease 2019; HCQ: hydroxychloroquine. #: >70% agreement among Task Force members.

    • TABLE 3

      Summary of research priorities

      The Task Force identified the following research needs for previously hospitalised patients with COVID-19 pneumonia who were discharged in the past 30–60 days
      Routine testing to establish a new baseline?
       Pulmonary function testing
       6-min walk test
       Computed tomography of the chest
       Transthoracic echocardiography
       Cardiopulmonary exercise testing
      Continue prophylactic anticoagulant therapy as outpatients until the D-dimer normalises?
      Serological testing to assess immune response to the infection?
      Attending medical visits without screening for active infection if serological tests positive?
      Serological testing of household contacts to determine if mild or asymptomatic infection?
      Referral to a multidisciplinary clinic for post-intensive care syndrome?
      Referral to pulmonary rehabilitation regardless of lung function?
      Routine screening for:
       Cognitive impairment
       Depression
       Anxiety
       Post-traumatic stress disorder
      Routine referral for mental health counselling?

      COVID-19: coronavirus disease 2019.

      Supplementary Materials

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        Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

        Supplementary_material ERR-0287-2020_Supplementary_material

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      Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)
      Chunxue Bai, Sanjay H. Chotirmall, Jordi Rello, George A. Alba, Leo C. Ginns, Jerry A. Krishnan, Robert Rogers, Elisabeth Bendstrup, Pierre-Regis Burgel, James D. Chalmers, Abigail Chua, Kristina A. Crothers, Abhijit Duggal, Yeon Wook Kim, John G. Laffey, Carlos M. Luna, Michael S. Niederman, Ganesh Raghu, Julio A. Ramirez, Jordi Riera, Oriol Roca, Maximiliano Tamae-Kakazu, Antoni Torres, Richard R. Watkins, Miriam Barrecheguren, Mirko Belliato, Hassan A. Chami, Rongchang Chen, Gustavo A. Cortes-Puentes, Charles Delacruz, Margaret M. Hayes, Leo M.A. Heunks, Steven R. Holets, Catherine L. Hough, Sugeet Jagpal, Kyeongman Jeon, Takeshi Johkoh, May M. Lee, Janice Liebler, Gerry N. McElvaney, Ari Moskowitz, Richard A. Oeckler, Iñigo Ojanguren, Anthony O'Regan, Mathias W. Pletz, Chin Kook Rhee, Marcus J. Schultz, Enrico Storti, Charlie Strange, Carey C. Thomson, Francesca J. Torriani, Xun Wang, Wim Wuyts, Tao Xu, Dawei Yang, Ziqiang Zhang, Kevin C. Wilson
      European Respiratory Review Sep 2020, 29 (157) 200287; DOI: 10.1183/16000617.0287-2020

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      Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)
      Chunxue Bai, Sanjay H. Chotirmall, Jordi Rello, George A. Alba, Leo C. Ginns, Jerry A. Krishnan, Robert Rogers, Elisabeth Bendstrup, Pierre-Regis Burgel, James D. Chalmers, Abigail Chua, Kristina A. Crothers, Abhijit Duggal, Yeon Wook Kim, John G. Laffey, Carlos M. Luna, Michael S. Niederman, Ganesh Raghu, Julio A. Ramirez, Jordi Riera, Oriol Roca, Maximiliano Tamae-Kakazu, Antoni Torres, Richard R. Watkins, Miriam Barrecheguren, Mirko Belliato, Hassan A. Chami, Rongchang Chen, Gustavo A. Cortes-Puentes, Charles Delacruz, Margaret M. Hayes, Leo M.A. Heunks, Steven R. Holets, Catherine L. Hough, Sugeet Jagpal, Kyeongman Jeon, Takeshi Johkoh, May M. Lee, Janice Liebler, Gerry N. McElvaney, Ari Moskowitz, Richard A. Oeckler, Iñigo Ojanguren, Anthony O'Regan, Mathias W. Pletz, Chin Kook Rhee, Marcus J. Schultz, Enrico Storti, Charlie Strange, Carey C. Thomson, Francesca J. Torriani, Xun Wang, Wim Wuyts, Tao Xu, Dawei Yang, Ziqiang Zhang, Kevin C. Wilson
      European Respiratory Review Sep 2020, 29 (157) 200287; DOI: 10.1183/16000617.0287-2020
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